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Full text of "U.S. Navy Medicine Volume 68, Number 1 January 1977"

VADM WUlard P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM Paul Kaufman, MC, USN 

Deputy Surgeon General 

EDITOR 

Sylvia W. Shaffer 

MANAGING EDITOR 

June Wyman 

ASSISTANT EDITOR 

Virginia M. Novinski 

EDITORIAL ASSISTANT 
Nancy R. Keesee 

CONTRIBUTING EDITORS 

Contributing Editor-in-Chief: 
CAPT CM. Herman, MC, USN 
Aerospace Medicine: CAPT M.G. Webb 
(MC); Dental Corps CAPT E.E. McDonald 
(DC); Education: CAPT J.S. Cassells 
(MC); Fleet Support: CAPT R.W, Jones 
(MC); Gastroenterology: CAPT DO. Caste]] 
(MC); Head and Neck CAPT R.W. Cantrell 
(MC); Hospital Corps: HMCM H.S. 
Anderson; Legal: LCDR R.E. Broach 
(JAGC); Marine Corps: CAPT D.R. Hauler 
(MC); Medical Service Corps: LCDR J.T. 
Dalton (MSC); Naval Reserve CAPT N.V, 
Cooley (MC, USN); Nephrology: CDR J.D. 
Waflin (MC); Nurse Corps: CAPT P.J. 
Elsass (NC); Occupational Medicine: CAPT 
G.M. Lawton (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT R.W. Steyn (MC); Research: CAPT 
C.E, Brodine (MC); Submarine Medicine: 
CAPT HE. dick (MC) 



POLICY: U.S. Navy Medicine is ill official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Medical De- 
partment officers of the Regular Navy and Naval Reserve 
official and professional information relative to medicine, 
dentistry, and the allied health sciences. Opinions 
expressed are those of the authors and do not necessarily 
represent the official position of the Department of the 
Navy, the Bureau of Medicine and Surgery, or any other 
governmental department or agency. Trade names are used 
for identification only and do not represent an endorsement 
by the Department of the Navy or the Bureau of Medicine 
and Surgery. Although U.S. Navy Medicine may cite or 
extract from directives, official authority for action should 
oe obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department officers via the Standard 
Navy Distribution List. Requests to increase or decrease the 
number of allotted copies should be forwarded to U.S. Navy 
Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor. U.S. Navy Medicine. Department of 
the Navy, Bureau of Medicine and Surgery (Code 0010), 
Washington, DC. 20372. Telephone: (Area Code 202) 
254-4253, 254-4316, 254-4214; Autovon 294-4253, 294-4316, 
294-4214. Contributions from the field are welcome and will 
be published as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor- 
dance with Department of the Navy Publications and 
Printing Regulations (NAVEXOS P-35). 



NAVMED P-S088 



U.S.NAVY 




Volume 68, Number 1 
January 1977 



1 New Year's Message to Medical Department Members 

2 From the Surgeon General 

3 Department Rounds 

National Children's Dental Health Week 

4 BUMED SITREP 

5 Letters 

Special Report 

The Surgeon General's Eighth Annual Specialties Advisory 
Conference and Committees' Meeting 

6 Program 

6 Welcoming Remarks 
RADM J. W. Cox, MC, USN 

7 Perspectives of the Navy Medical Department 
VADM W.P. Arentzen, MC, USN 

10 A Rationale for Graduate Medical Education in the Navy 

CAPT J.S. Cassells, MC, USN 
13 Manpower: The Requirement Base 

RADM E.J. Rupnik, MC, USN 
16 Medical Corps Manpower 

CAPT R.E. Strange, MC, USN 
19 Operational Medicine Support: Another Look 

CAPT J.J. Quinn, MC, USN 

22 Continuing Medical Education: An Expanding Requirement 
CDR B.G. Mc Alary, MC, USN 

23 Panel Discussion 

27 Notes and Announcements 

Dental continuing education courses set for March . . . Continuing 
education for Navy nurses . , . Learning disability clinic opens at 
NRMC Corpus Christi 

28 Reserves 

Project Readiness '77 

COVER: Medical support for the operating forces was emphasized at 
the Surgeon General's Eighth Annual Specialties Advisory Conference 
and Committees' Meeting, held last September. (A report of the pro- 
ceedings of the first plenary session begins on page 6.) Our cover shows 
LT Jay 0. Brainard, MC, USNR, then a flight surgeon trainee, learning 
to provide needed support in a practice drill at the Naval Aerospace 
Medical Institute, Pensacola, Fla. With him is HM3 J. Applegate, USN, 
then assigned to HCT-16, NAS Pensacola. LT Brainard is now the flight 
surgeon with Patrol Squadron 11, NAS Brunswick, Maine. 



TO ALL HANDS 



This will be another exacting year for Navy medicine. Our fleet and Marine units are being 
called upon as never before to provide the bulwark of our nation's defense. We must 
recognize that our commitment in support of their efforts is our reason for being, and that 
this commitment must be firmly established as the first priority for our resources and 
efforts. 

Navy medicine will always make demands that the fainthearted call excessive, but the hardy 
call challenging. Only the skilled professional can do your work at all; only the dedicated can 
do it well; and only the deeply compassionate can do it superbly. I know from working with 
you on the Navy health care team that your ability and your performance are both 
unquestionably superb. 

I am confident you will find in 1977 ample opportunity to grow in service to your country and 
your patients. May the new year bring you the professional and personal rewards you so 
richly deserve. 






M 




W.P. Arentzen 

Vice Admiral, MC, USN" 

Surgeon General of the Navy 



.*■■*.•* 










V 





From the Surgeon General 



Patients Come First 



Some of the most frequent complaints 
we receive at the Bureau of Medicine 
and Surgery concern the failure of 
Medical Department personnel to show 
courtesy, tact and sympathetic regard 
for patients and their families. The 
failure is especially noticeable at points 
of initial patient contact — central ap- 
pointment desks, telephone switch- 
boards, patient affairs offices, emer- 
gency rooms, pharmacies, laboratories, 
records offices, information desks, gate- 
houses, and walk-in or specialty clinics. 

Military and civilian personnel who 
work in these areas where patients first 
"meet" the hospital play a crucial role 
in conveying the feeling that Navy 
medicine is there to help the patient. It 
is essential that the assistance provided 
truly reflect the spirit of caring for 
which the Navy Medical Department 
stands. No matter how excellent and 
expert the medical care itself, an early 
impression of nonchalance, disregard, 
rudeness or neglect of the patient's 
needs reflects poorly on the facility's 
efforts and achievements. In particular, 
staff members should maintain a pro- 
fessional attitude throughout their 
work. There is no place for off-handed 
remarks or jokes in the presence of pa- 
tients; what may be commonplace to us 
may frighten the patient, or be easily 
misinterpreted. 

By example and precept we must 
show that no complaint is ever too triv- 
ial: every problem deserves our best re- 
sponse. 



My first concern is and always will be 
sympathetic support for the patients 
who have been entrusted to us. To 
ensure that the issue of courtesy 
receives the command attention it 
deserves, I have directed that each 
person assigned to an initial patient 
contact area receive instruction in 
dealing with patients. The training cur- 
riculum will stress the objectives of the 
Navy medical system and the important 
role of the Medical Department member 
in every area of patient care. This 
educational effort should be continuous, 
to meet the needs of personnel turn- 
over. 

I have also asked that a copy of each 
training curriculum be forwarded to the 
Bureau of Medicine and Surgery, along 
with a description of other action com- 
mands are taking to ensure courteous 
response to patient needs. In future 
inspections, the Inspector General will 
be paying close attention to our profes- 
sional performance in initial patient 
contact areas. 

I know you share my conviction that 
the quality of Navy medical care must 
not be degraded by thoughtlessness or 
other evidence of not caring about 
patients. I feel certain that renewed 
efforts to correct such deficiencies will 
reassure our beneficiaries that — in Navy 
Medical Department facilities — patients 
come first. 



'/I/! 




VADM Arentzen 




W.P. Arentzen 

Vice Admiral, MC, USN 

Surgeon General of the Navy 



U.S. Navy Medicine 



Department Rounds 



During National Children's Dental 
Health Week the message is 

Smile, America! 



Navy dental officers and dental 
technicians are preparing their sup- 
port for National Children's Dental 
Health Week, to be observed 6-12 
Feb 1977. Sponsored by the Ameri- 
can Dental Association to encourage 
good oral hygiene habits among 
children, the week repeats last 
year's theme: "Smile, America!" 

Wherever possible during Na- 
tional Children's Dental Health 
Week, the Navy Medical Depart- 
ment will sponsor dental education 
and treatment programs for the 
children of Navy and Marine Corps 
members, so long as these pro- 
grams do not interfere with the 
primary mission of providing dental 
services for active-duty personnel. 
Programs will usually be conducted 
during off-duty time to enable the 
largest number of children and 
parents to participate. 

Imaginative. Successful projects 
undertaken at Navy medical and 
dental facilities during the 1976 Na- 
tional Children's Dental Health 





Good oral hygiene is highlighted . . , 

Week may inspire equally imagina- 
tive efforts this year. Here are some 
highlights of last year's programs: 
• At Naval Regional Medical Cen- 
ter, Corpus Christi, Tex., children 
of active-duty and retired military 
personnel attended a slide show 
that explained the dangers of dental 
plaque and the consequences of 
ignoring oral hygiene. Next, dental 
technicians demonstrated proper 
brushing and flossing techniques. A 
dental officer then examined each 
child's teeth and applied topical 
stannous fluoride. The children left 
with gift packs containing a tooth- 
brush, toothpaste, disclosing wa- 
fers, dental floss and a disposable 



during dental health week. 



© 1976 American Dental Association 




American Dental Association poster 



tut 9 ■ 



Clever teaching techniques help . . 

Volume 68, January 1977 




interest children in dental health. 




Checkup time for a Navy dependent 



plastic mirror. Parents were notified 
if their children needed dental treat- 
ment, and were reminded to visit 
their family dentist regularly. 

• Dental officers of the USS Grand 
Canyon (AR-28) manned a pierside 
preventive dentistry unit at Naval 
Air Station, Mayport, Fla., where 
they cleaned and examined the 
teeth of 156 children, including 
many dependents of Grand Canyon 
personnel. 

• Art projects undertaken by stu- 
dents from the Matthew C. Perry 
School at Marine Corps Air Station, 
Iwakuni, Japan, helped bring the 
"Smile, America!" theme to life. 
One kindergarten class constructed 
a huge papier-mache tooth; a 
fourth-grade class wrote and illus- 
trated stories about animated tooth- 
brushes and tubes of toothpaste. 
Seven of the children appeared with 
their art teacher on a local television 
show to talk about their projects and 
the importance of dental health. 

• At Naval Training Center, Orlan- 
do, Fla., dental technicians wrote a 
skit on dental care, and performed it 
in six area schools. Television clown 
Ronald McDonald hobnobbed with 
children in the dental clinic, staging 
games and talking about dental 
care. During the week-long pro- 
gram, dental officers examined 
more than 1,000 children. 

• At Naval Training Center, San 
Diego, Calif., a cartoon slide pro- 
gram introduced children to princi- 
ples of oral hygiene, including the 



signs of early dental disease, how to 
remove plaque, and how to check 
plaque removal with disclosing tab- 
lets. Later, in a plaque control room 
and under the supervision of a 
dental technician, parents and chil- 
dren looked through a phase micro- 
scope at live plaque microorga- 
nisms, and tried out techniques of 
plaque control. Parents stood at the 
side of the dental officer during 
their children's examination, and 
were shown where their children's 
oral hygiene needed improvement. 
• At Naval Dental Clinic, Camp 
Pendleton, Calif., a dental officer 
and dental technician visited each 
school on base. The dental team 



used cartoon posters to explain the 
causes of tooth decay, and asked 
some students to chew disclosing 
tablets so classmates could see the 
plaque-covered areas. In one of the 
most successful projects, a few stu- 
dents dressed in pillow cases to look 
like teeth, and other students used 
these "pillow-case teeth" to prac- 
tice flossing and brushing. 

Armed with such appealing 
teaching techniques, Navy dental 
teams got their message across last 
year. This year, parents and chil- 
dren will again benefit as Navy 
dental officers and technicians lend 
their talents to support National 
Children's Dental Health Week. 



BUMED SITREP 



MEDICAL RECORDS . . . Recurring 
errors in the maintenance and disposi- 
tion of health care treatment records 
have been noted by the Inspector Gen- 
eral, Medical, and other inspection and 
audit teams. To help Medical Depart- 
ment activities review their record- 
keeping, BUMED Notice 6150 of 2 Nov 
1976 identifies the most commonly re- 
ported errors, and for each error cites 
the applicable directive, 

AUDIT TIPS . . . Medical Department 
activities should review these manage- 
ment areas: 

• NAVSO P-3006, par. 501-2 requires 
quarterly reviews of unfilled orders. 

• BUMED Instruction 6700.36 requires 
establishment of a preventive mainte- 
nance program for medical equipment. 

• NAVMED P-117, par. 21-4 requires 
monthly or, if necessary, more frequent 
surprise inventory of controlled sub- 
stances, to be accomplished by an ap- 
pointed inventory board. 

• BUMED Instruction 6770.2B requires 
that a linen committee be established, 
and that linen be properly accounted for 
and secured. 

AMHTS DEBUT SET ... The National 
Naval Medical Center is readying a site 
for the Navy's first automated multi- 
phasic health testing system (AMHTS), 
scheduled to be installed this spring. 
Plans call for a staff of one medical offi- 
cer, one nurse, 12 health screening 



technicians and four clerical workers. 

The computerized system measures 
physiological performance, such as 
visual and auditory acuity, and prints 
the results on Standard Form 88 or in 
narrative form. Physical examinations 
of active-duty personnel and pre-admis- 
sion screening examinations will be con- 
ducted through the new system. 

DR. CURRERI LEAVES USUHS . . . 

Anthony R. Curreri, M.D., first presi- 
dent of the Uniformed Services Univer- 
sity of the Health Sciences, resigned 
that post in November after a three-year 
term to resume his former position as 
professor of surgery at the University of 
Wisconsin School of Medicine. 

CLINIC CLOSES . . . The Potomac 
Annex branch of Naval Regional Medi- 
cal Clinic, Washington, D.C., will be 
disestablished 1 March 1977. Health 
records for active-duty personnel are 
being transferred to the branch clinic at 
the Navy Annex, Arlington, Va.; rec- 
ords of non-active-duty health care 
beneficiaries are being sent to the out- 
patient clinic at the National Naval 
Medical Center, Bethesda, Md. Pa- 
tients formerly seen at the clinic may 
receive care at the National Naval 
Medical Center, and at nearby branch 
clinics. Podiatry and eye clinics will be 
added to the Washington Navy Yard 
clinic, while dermatology services there 
will be discontinued. 



U.S. Navy Medicine 



Letters 



TURNOVER TIME 

I'd like to give my cohorts who await 
their "watch" at sea some insight into 
fleet medical support. My own tour was 
a "Med cruise" aboard the USS Detroit 
(AOE-4) from 19 Aug 1975 to 27 Jan 
1976. When the Detroit was replaced in 
the Mediterranean by the USS Seattle 
(AOE-3), I provided the following 
turnover information to the Seattle's 
medical officer: 

Welcome to the Mediterranean Sea, 
your habitat for the next several 
months. You will find the pace demand- 
ing, at times invigorating and at times 
frustrating. You will soon learn (if you 
have not already) that you are first a 
naval officer, then a general medical 
officer, internist, surgeon, urologist, 
psychiatrist, orthopedic surgeon, radiol- 
ogist, ophthalmologist and dermatolo- 
gist all rolled into one! 

Now a few words about division per- 
sonnel. Your chief petty officer is a 
valuable asset to your shipboard health 
care team. He has had years of experi- 
ence as a hospital corpsman and admin- 
istrator, and he can help you hurdle 
mountains of red tape. Let him run 
many of the routine operations of the 
department. If you usurp his authority 
by making every decision yourself, you 
will find yourself engulfed by a moun- 
tain of paperwork that could easily have 
been delegated. So share some of the 
burden; there will be plenty of times 
when, as department head, you will 
have to make ultimate decisions. 

Your supply petty officer is also an 
important member of your team. He 
must make a daily mental inventory of 
your materiel, and must know when, 
where and how much to order so you 
don't run out. You're not tied to a pier 
anymore, so you can't get daily sup- 
plies. The medical facilities at your 
ports of call will provide supplies in 
emergencies, but they have limited 
budgets and inventories. So order your 
supplies through the established fleet 
supply procedures, and work out your 
needs through your own budget and 
with your own supply petty officer. 

An AOE — a fast combat support 
ship — can be a dangerous place to 
work, with an abundance of heavy 
machinery, span wires, and fueling 
rigs. During underway replenishment 
exercises and routine evolutions, your 



medical department personnel should 
watch for any unsafe activities or viola- 
tions of safety rules. 

The types of injuries we encountered 
most frequently on the Detroit were 
musculoskeletal injuries and injuries 
caused by chemicals. Navy distillate 
fuel, JP-5 turbine fuel, and Cellulube- 
type hydraulic fluids can get into the 
eyes of crewmembers. Always have a 
liter of normal saline near your surgical 
scrub sink for irrigating the eyes. 

Another common problem was digital 
fractures when fingers and toes were 
crushed by hatches, doors and machin- 
ery. One man suffered an angular 
avulsion through the distal phalanx 
when a barrel dropped on his finger; 
adequate debridement and a pedicle 
graft, performed on board immediately 
after the injury occurred, saved the 
terminal aspect of his finger. 

Early in the cruise we saw many 
pyogenic and fungal skin infections. 
The weather was hot, the men worked 
long hours at underway replenishment 
stations, and personal hygiene suffered. 
In spite of aggressive therapy, many 
man-hours were lost, primarily because 
of pyogenic infections; we confined men 
with these infections to the ward to 
prevent the infection from spreading 
among the crew. We encouraged the 
men to practice better hygiene, and the 
problem was eventually solved. 

A common problem on ships that 
carry groceries is insect infestation. Our 
commanding officer invited staff mem- 
bers of the Environmental and Preven- 
tive Medicine Unit No, 7 in Naples to 
come aboard. Their assistance resulted 
in a dramatic improvement in our insect 
problem. They also pass on other infor- 
mation useful for ships entering the 
Mediterranean. You will find their visit 
highly valuable, but remember — they 
can't visit you unless they receive an 
invitation from your command. 

Because you are on an AOE, you have 
helicopters at your disposal for medical 
emergencies, assuming you are within 
flying range of a naval shore facility or a 
carrier. If you have an emergency or a 
serious medical problem and have the 
option to use medical evacuation, use it. 
We had two such emergencies: One 
man presented with a textbook case of 
gallbladder obstruction. We happened 
to be within range of the naval clinic at 
Sigonella, Sicily, so we wired ahead for 
assistance, and within minutes of touch- 
ing ground in Sigonella, our patient was 
on an aeromedical evacuation plane to 
Naples. In fact, he was in Naples before 



we could get from Sigonella back to the 
Detroit. 

Our second medical evacuation in- 
volved a crewmember who had an idio- 
syncratic reaction to an influenza im- 
munization. Shortly after he was- vac- 
cinated, he presented with malaise and 
a temperature that climbed to 105.8° 
before we saw evidence of lysis. Even 
then, the patient's temperature re- 
mained at 104°. By the time we got the 
patient to Sigonella, his temperature 
was down to 102° and his reaction was 
subsiding. He was flown to Naples, ob- 
served, and released in a few days. 

As medical officer, you should pro- 
vide the most sophisticated care you can 
for the seriously ill patient. That last pa- 
tient might have recovered on board, 
but had he died, we would have had to 
ask ourselves, "Did we use every 
means at our disposal to provide the 
best possible care?" 

One last recommendation: take ad- 
vantage of your tour. Go ashore when 
possible and get your mind off your 
work for awhile! 

LT Robert J. Allen, MC, USNR 
NRMC Portsmouth, Va. 23708 

FLEET MARINE FORCE 

I read with interest the article entitled 
"Next Stop: Newport" [US NAV MED 
67(3):14, March 1976]. The article, 
which appeared to cover all information 
medical students may need while at 
Newport, did not mention an area that 
could impact on the medical officer's 
future assignments: the role of the med- 
ical officer when serving with the Fleet 
Marine Force. While the omission was 
probably an oversight, I would like to 
point out that some of the students may 
be assigned to a tour of duty with the 
Fleet Marine Force, and that the course 
content at Newport should include infor- 
mation concerning duty with the Ma- 
rines. 

CAPT D.R. Hauler, MC, USN 
Headquarters U.S. Marine Corps 
Washington, D.C. 20380 

As CAPT Hauler notes, the omission 
of duty with the Fleet Marine Force was 
an oversight. In the Officer Indoctrina- 
tion School curriculum, 12 hours are 
devoted to Medical Department topics; 
the rest of the time is given to general 
naval orientation and training. Part of 
that 12-hour medical track is devoted to 
the various types of duty a medical offi- 
cer might be called upon to perform, 
including duty with the Fleet Marine 
Force.— BUMED Code 0011-1. 



Volume 68, January 1977 



Special Report 



The Surgeon General's 8th Annual Specialties 
Advisory Conference and Committees' Meeting 

Accountability in Graduate Medical Education 



This conference was held 20-24 Sept 1976 in Arlington, Va. 
The following report of this annual session represents an 
edited (sometimes paraphrased or abbreviated) version of the 
remarks and presentations of specified individuals. Their 
comments do not necessarily reflect official views of the Navy 
Department or the naval service at large. — Ed. 



PROGRAM 

Monday, 20 Sept 1976 

1300 Registration 

Begin review of applicants 
1900-1930 Committee chairmen meeting 

Tuesday, 21 Sept 1976— First Plenary Session 

0830-0845 Administrative Announcements 

CAPT J.S. Cassells, MC, USN 
0845-0900 Welcoming Remarks 

RADM J. William Cox, MC, USN 
0900-0930 A Rationale for Graduate Medical Education in the 

Navy 

CAPT J.S. Cassells, MC, USN 
0950-1020 Manpower — The Requirement Base 

RADM E.J. Rupnik, MC, USN 
1020-1035 Medical Corps Manpower 

CAPT R.E. Strange, MC, USN 
1035-1100 Operational Medicine Support: Another Look 

CAPT J.J. Quinn, MC, USN 

CAPT J.D. Bloom, MC, USN 
1100-1130 Continuing Medical Education: An Expanding 

Requirement 

CDR B.G. McAlary, MC, USN 
1130-1215 Panel Discussion 

RADM J.W. Cox, MC, USN 

RADM R. Laning, MC, USN 

RADM E.J. Rupnik, MC, USN 

CAPT J.S. Cassells, MC, USN (moderator) 

CAPT J.J. Quinn, MC, USN 

CAPT R.E. Strange, MC, USN 

CDR B.G. McAlary, MC, USN 
1215-1230 Instructions to the Specialties Advisory Committee 

Conferees 

CAPT J.S. Cassells, MC, USN 
1330 Committee workshops. Review of applicants. Ap- 
pointments with BUMED Codes 31, 311, etc. 



Wednesday, 22 Sept 1976 — Second Plenary Session 

0830-0930 Perspectives of the Navy Medical Department 
VADM W.P. Arentzen, MC, USN 

1000-1200 Committee workshops 

1300 Committee workshops. Appointments with BU- 
MED Codes 31, 311, etc. 

Thursday, 23 Sept 1976 

0800-1200 Committee workshops. Continue review of appli- 
cants at individual committee chairmen's discre- 
tion. 
1400 Review and collation of slates. Compilation of 
major issues resulting from committee workshops. 

Friday, 24 Sept 1976— Third Plenary Session 

0900-1015 Discussion of major issues. Surgeon General com- 
mentary. 

1035-1140 Discussion of major issues continued. 

1140-1200 Closing Summation 

RADM J. William Cox, MC, USN 

FIRST PLENARY SESSION 

Welcoming Remarks 

RADM J.W. Cox, MC, USN 

Special Assistant for Medical Department Education 

and Training, BUMED Code 0011 

Last year, I said in the concluding remarks that the 
Specialties Advisory Conference is not an infant. It is a 
mature, effective, responsible and experienced con- 
gress of professionals who gather each year to address 
the issues, to lay plans for answering future problems, 
and to determine strategies for accommodating to an 
ambiguous and often hostile environment. 

The record of this conference over the last eight years 
speaks for itself. It is unnecessary for me to make an 
inventory of numerous innovations and improvements 
that have transpired in the Medical Department as a 
direct or indirect outcome of deliberations at SAC. 
When we began, most of our efforts were directed at 
problems related to graduate medical education. But as 

U.S. Navy Medicine 



their experience and knowledge and sophistication 
grew, the SAC committees addressed other issues only 
indirectly related to graduate medical education and 
have helped bring about many improvements in the 
Navy Medical Department. 

It is no secret that since 1973 the base budget for 
education and training, across all appropriation lines, 
has fallen approximately 30%. Nevertheless, most es- 
sential programs have been maintained. Believe it or 
not, when we look at priorities and consider the essen- 
tials, we are almost in as good a position as we were in 
1973. That achievement is the result of the sage advice 
and counsel of this conference. You have truly demon- 
strated accountability in graduate medical education. 

In welcoming you, I must point out that the environ- 
ment is even more hostile as we face fiscal year 1977. 
Bear this in mind as you listen to the SAC speakers, 
who will discuss some of the major issues and problems 
facing us with regard to medical education and the 
operation of specialties within the Medical Department. 
As you move into your individual groups, please re- 
member that this is primarily a forum for the transfer of 
information, and for some exchange of unsubstantiated 
opinion. After an appropriate amount of information 
exchange, with a minimum amount of unsubstantiated 
opinion exchange, I ask that you try to reach a consen- 
sus — one that recognizes the reality of our situation but 
is not bound by artificial constraints. Try to articulate 
the alternatives that are available, and make responsi- 
ble and thoughtful recommendations for mechanisms 
by which we can ameliorate existing problems, cope 
with future problems, and accommodate to an 
ambiguous and hostile environment. 

Your reports will be reviewed in detail at the Bureau 
of Medicine and Surgery, although reports from indi- 
vidual committees do not automatically generate a 
Bureau action. After you have made the reports, if you 
believe action is required from your own medical cen- 
ter, draw up the plan and forward it through channels 
with specific recommendations and resource require- 
ments, and we in the Bureau will consider it very 
seriously. 



VADM Arentzen (center) leads discussion at SAC 8 




Perspectives of the Navy 
Medical Department* 

VADM W.P. Arentzen, MC, USN 
Surgeon General of the Navy 

I am pleased and proud to be able to extend my be- 
lated welcome to you as you proceed with the work of 
the eighth annual Specialties Advisory Conference. 
From what I have been told, you have begun your de- 
liberations with the same spirit of enthusiasm and hard 
work I have learned to expect from the years many of us 
shared together in our hospitals. 

Looking out over the audience here, I must say it 
makes me a little homesick for the field, because you 
people are, believe it or not, where the real action is. 
You are the real front lines of Navy medicine. 

In this, my first time to address this conference, I will 
admit that my perspectives are still very much those of 
the commanding officer of a graduate training hospital. 
In my remarks today, I will try to combine that perspec- 
tive with the view I am rapidly gaining of the overall 
needs of the Navy, and to indicate to you the role for our 
programs which I wish to see emphasized and devel- 
oped. 

I am fully aware of the size of the job you are tackling 
in the several days of this conference. For my part, I 
want to avoid trying to channel your thoughts into pat- 
terns of thinking which are restrictive or limiting of the 
wide range of your imagination as you work to develop 
innovative approaches to meet our clear mandate: to 
match our training to the needs of the Navy, the 
Marines, and our entire beneficiary population. 

Consider this: 35,000 inpatient health care facilities; 
7,000 hospitals; 22,000 nursing homes; 4 million 
employees; 228,000 unoccupied beds; 14 million sur- 
gical procedures; 200 million outpatient hospital visits; 
800 million physician encounters; all at a direct cost of 
over $100 billion, of which well over $40 billion is 
funded by our federal government. This staggering 
total represents over 8% of our gross national product, 
and that figure could double, even triple within 10 
years. 

Is it any wonder that we, as part of this massive effort 
directed toward providing adequate health care for our 
nation, are subject to being counted and recounted, 
analyzed and scrutinized, scrubbed and rescrubbed as 
never before? The medical departments of the three 
armed services — existing as we do at the sufferance of 
Congress and its regulatory agencies — will be in the 
forefront of the effort to carve, mold and develop a 
health care system which can be controlled and paid 
for. 

In a study entitled "A Forward Plan for Health, FY 
1976-1980," published in June 1974 by the U.S. De- 

•VADM Arentzen's address was delivered at the second plenary session on 22 Sept 1976. 



partment of Health, Education and Welfare, a new 
doctrine is unabashedly presented: they wish to work 
with the Department of Defense and the Veterans Ad- 
ministration in opening health care facilities in "scar- 
city areas' ' to provide health care to civilians who other- 
wise would not have qualified for care. This policy — 
now only in its infancy — reflects a growing consensus at 
the federal level that high quality health care, and the 
resource base needed to achieve it, is unattainable 
except by government intervention. The architects of 
this master plan would try to correct what unquestion- 
ably are gross inadequacies, namely: 

• a shortage of health services personnel and facilities 
for the urban poor, and in the low population density 
areas of the country. 

• high and still rapidly rising costs of health services, 
with no indication that a leveling off point will be 
reached in the near future. 

• fragmentation of the health services system with, as 
a result, patients unable to find help, even when avail- 
able. 

• the perception that the fantastic financial, technolog- 
ical and human capital expenditures made by this 
country have not resulted in significant improvement in 
the nation's aggregate health level. 

The same perceived inadequacies which have forced 
development of a federal national health plan have 
further resulted in the military health system coming 
under the scrutiny of federal analysts. In the year since 
your last meeting, a joint task force from OMB, DOD 
and HEW has published a report entitled ' 'The Military 
Health Care Study." This report, the product of almost 
three years of work, will represent our "Forward Plan 
for Health." 

This report made recommendations which will 
impose on us a radically different Navy health services 
system than that which we presently operate. These 
things are happening: 

• Contingency requirements are being updated. Force 
size will be tied to that necessity. Training will be tied 
to contingency needs. 

• Capitation budgeting is being studied — not to deter- 
mine feasibility, but how to achieve it. 

• A uniform cost accounting system is being devel- 
oped. 

• The mechanism to update CHAMPUS reimburse- 
ment on an annual basis is being developed. 

• A CHAMPUS consumer appeal system is being ini- 
tiated. 

In addition to these changes, all of which are now 
happening, other recommendations of the report are 
being studied to determine how to implement them. 
These recommendations are: 

• A central entity to plan and manage health care deliv- 
ery programs in fixed facilities. 

• DOD contracting for health care in the U.S. 

• Offering beneficiaries the choice of alternate health 
care plans. 



In some form or another, these recommendations rep- 
resent the reality of the future. In some form or 
another, they will serve as the structural underpinning 
on which will be built the health care system of tomor- 
row's Navy. 

At the same time these portions of tomorrow's 
system are being formulated, the same restrictive phi- 
losophy has resulted in a loss of resources in OPN and 
O&MN dollars of almost $20 million over the past three 
years. In the same three-year period we have lost $12 
million from our training base. Simultaneously with 
these restrictions and losses in our resource base we 
have been asked to accommodate to the realities of the 
all-volunteer force, with its loss of draft-driven acces- 
sions and the superb Berry Plan resources. At the same 
time, the Congress has asked us to provide an 
increased opportunity for inpatient care in our medical 
facilities to reduce the outlay of CHAMPUS dollars. 
Our line and Marine leadership rightly expect and 
deserve an expanded capability in support of their 
mission. In addition, expanding technology, altered 
concepts and improved modes of patient care, increas- 
ing consumer demands, and even legislative action 
have contributed to the resource demand which we 
must accommodate if we are to continue to provide the 
level of care to which we are committed. 

Putting it bluntly, we are in a crisis. If we are to meet 
this crisis, if we are to manage the change and modify 
the impact of what we can see taking place around us 
and to us, it is mandatory that we look coldly and dis- 
passionately at our own internal institutions and 
processes to determine if they are what we think they 
are, doing what we think they do, and accomplishing 
what we know must be done. 

The most important and sensitive of these institu- 
tions is the graduate training hospital. Perpetuation of 
its role as a provider of trained specialists is your 
reason for being here. There is little question that this 
traditional and long revered role, with its concentration 
of specialist and technical resources, has resulted in the 
highest standards of patient care. However, it is this 
very concentration of talent — to the exclusion of our 
wider mission — and the denial of this talent to our 
operating forces and other health care units which have 
made our graduate training hospitals so sensitive to 
attack and dismemberment. This same intellectual elit- 
ism has contributed to the establishment of a two-caste 
Medical Corps: the first occupies the more favored 
positions in our major hospitals; the second is doomed 
to perpetual second-class status among our operational 
forces and at our less attractive duty stations. 

Please do not construe my remarks to mean that I 
advocate the downgrading of our graduate training 
hospitals. To the contrary, I am advocating their re- 
establishment on a foundation of relevance to and par- 
ticipation in the entire spectrum of Navy health care 
activity. What I ask you to consider is that we look upon 
our graduate training hospitals as educational regional 



U.S. Navy Medicine 



centers — educational regional centers which will fur- 
nish the leadership core around which training pro- 
grams can be built, not only in the clinical specialties, 
but in all the wide areas of medicine pertinent to the 
Navy's needs. I visualize our teaching centers as dy- 
namic hubs of know-how, with people and equipment 
constantly interchanging and fully interfacing with the 
region they serve, and with the Navy as a whole. 

This is not empty rhetoric. In my remarks at the 
recent retirement of VADM Custis, I clearly stated that 
I am totally dedicated to the enduring support of our 
fleet and our Marine Corps, and that I considered 
nothing else as important. If we fail to recognize this 
reality and to exploit the uniqueness of Navy medicine 
in the totality of fleet and Marine support, then we will 
write our own obituary. 

We have made a start. Based on previous policy, as 
you make your selections for training programs this 
week you will be granting priority to the medical officer 
who has served in the fleet. Graduating seniors 
selected for first-year training positions next July will 
reflect our policy of expecting most of them to serve in 
an operational support role before continuing with more 
specialized training. 

Several weeks ago, I requested Admiral Cox and his 
staff to prepare a curriculum for basic operational and 
shipboard medicine. This has been done to my full sat- 
isfaction. This curriculum, directed toward preparing 
our trainees at graduate level one to assume meaning- 
ful and knowledgeable roles in operational support, will 
be initiated this year in our graduate training hospitals. 
It will be your responsibility to make it work. I am fully 
aware of the accommodations on your part which this 
will require. 

One of the major problems which I alluded to earlier 
is the two-caste system — operational and hospital- 
based corps working independently of each other. Per- 
petuation of this dichotomy and the resultant disen- 
franchise ment has led to the increasing dissatisfaction 
of many excellent physicians who have, or would have, 
chosen this career pathway. Our hospital-based 
Medical Department has lost sight of the reality that 
the operational officer is in every sense of the word a 
physician. He, too, wants, expects and deserves the 
opportunity for professional development. As a physi- 
cian, he should be provided an opportunity to interact 
with the wide range of patients enjoyed by his hospital 
colleagues. 

Sea tours and frequent moves further contribute to 
the disruptiveness of his career. Is it any wonder that 
we have difficulty maintaining the numbers we 
require? I propose to change this. I am directing that 
opportunities be provided for this dedicated group of 
physicians to return to our hospitals for abbreviated 
periods of training, a so-called "mini-residency." This 
mini-residency will provide, on an "as needed" basis, 
training in clinical areas which will complement their 
not inconsiderable skills and make it possible for them 



to serve full and meaningful tours in our large hospitals 
and teaching centers, gaining and regaining the patient 
care and hospital experience they have so frequently 
lacked. 

These initiatives, together with the development of 
the new operational medicine training continuum, will 
help us achieve the professionalism and expertise we 
need to support the operational Navy, and will provide 
career development for physicians involved in opera- 
tional medicine. 

As a further step towards integrating our corps, I am 
insistent that our senior clinicians be assigned under 
the single manager pool concept to billets on ships and 
with our Marine units. This policy, combined with a 
policy of bringing operational specialists back to the 
hospital environment, will ensure that our Navy 
Medical Department is truly a team — a team in which 
each member knows the full ramification of the Navy of 
which he is a part. 

The graduate training hospitals, which you so ably 
represent, are both our failure and our future. They are 
our failure because they have developed in a direction 
which does not recognize the true range of the Navy 
mission. The narrow parochialism we have allowed to 
continue has fostered an isolation from the realities of 
today. Go back to your deliberations, and eventually to 
your hospitals, and ask yourselves these questions: 

Is the first priority of your command patient care? 
We must never lose sight of why we exist. 

Are you training in the most efficient and effective 
manner possible? Are you using the tremendous 
potential of your trainees to deliver better patient care? 

Are you providing the type of training needed? Have 
you yourselves made an unqualified commitment to 
providing the spectrum of training we need? Are you 
yourselves ready and able to assist in this effort? 

Are you using the full potential offered by your 
regional clinics to teach ambulatory care medicine? 

Are you using the full potential offered by the opera- 
tional units and facilities in your region to augment 
your operational medicine training? 

Are you making it possible for the operational medi- 
cal officers in your regions to avail themselves of train- 
ing opportunities in your hospitals? 

Are you helping to provide needed training in clinical 
skills for the independent duty corpsmen and crew- 
members assigned to ships in your area? 

Have you clearly thought out the role of the hospital 
in the overall Navy Medical Department teaching ef- 
fort? Are you doing what you should be doing? Should 
your role be changed? Should you have different pro- 
grams? You are in a better position to assess these 
things than we are. 

Have you created an environment for education? Is it 
vibrant and vital? Is it exciting? If not, why not? 

Have you looked closely at the medical schools in 
your area? Have you developed as close a supportive 
partnership, within your resources, as you can? I am 



Volume 68, January 1977 



convinced that when the final showdown comes, having 
the civilian medical education community in our corner 
will be one of our greatest assets. 

Is your library the best possible? Have you taken 
every opportunity to develop short courses, seminars 
and workshops within your region? Are your physicians 
able to avail themselves of travel opportunities for con- 
tinuing education? I am insistent that available funds 
be used for this purpose and not directed to other areas. 

Are you assessing the role of each officer on your 
staff and in your department? What is his or her contri- 
bution? We cannot afford the luxury of noncontribu- 
tion; we cannot afford dead wood. We must constantly 
examine, review and reappraise each member of our 
force to ensure maximum effectiveness. 

Are you innovative? Our resources are limited. I see 
no indication, at least in the near future, that they will 
be any less so, nor that our responsibility will lessen. 
Effective management must be sensitive to continuing 
change for improvement. Our results must be the 
measure of our success. 

The Navy — and our Bureau — is presently engaged in 
a program of management by objectives. For me the 
concept is extremely simple. There need be only one 
objective: to support our Navy and Marines to the best 
of our ability. Our commitment to this objective must be 
total. I know you share it with me. 

You are our leaders. Your talent and efforts are 
essential if we are to guide our system through our tur- 
bulent future. Your past record is superb. 1 have faith in 
all of you. There is no doubt that you can meet today's 
new challenge. We depend on your efforts. Tomorrow's 
Medical Department rests squarely in your hands. 

A Rationale for Graduate 
Medical Education in the Navy 

CAPT J.S. Cassells, MC, USN 

Deputy Special Assistant for Medical Department 

Education and Training, BUMED Code 0011-1 

It is ironic that "A Rationale for Graduate Medical 
Education" should be the subject of a presentation at a 
specialties advisory conference in its eighth year. 
Nevertheless, the subject is one that requires a state- 
ment now. 

Three of the questions most commonly asked about 
our graduate medical education programs are: How 
much do they cost? Why do we train our people at all? 
To what extent do the training programs create a work- 
load that would not otherwise exist? On the surface 
they appear to be rather straightforward questions, but 
there are constraints on our answers. This is the age of 
the systems analyst. Moral commitments, words like 
"quality," and so forth are not quantifiable, and there- 
fore cannot be reduced to numbers; so these important 



considerations are not permitted to contaminate our re- 
sponses to the questions. 

There was a time when we didn't have graduate 
medical education in the Navy. Does anybody remem- 
ber what it was like? I think it might be useful to look 
briefly at the trends in naval medical education over the 
past 50 years. This period can be split into four separate 
eras characteristic of Navy medicine in general. The era 
from 1920 to 1940 was the period of pre- specialization. 
From 1941 to 1945 was, of course, the period of the 
Second World War. From 1946 to approximately 1973, 
an organized Navy health care system was developed. 
Since 1973 we have been in an era of consolidation. 

As early as 1920, the Navy recognized the legitimacy 
of internships: year- long periods of supervised hospital 
experience to develop practical skills were authorized, 
and used to help physicians make the transition from 
civilian medical- school graduate to practicing general 
medical officer. Until 1940, structured education was 
limited. The active- duty population had been demobi- 
lized after World War I and the number of Medical 
Corps officers was miniscule compared to today. 
Cruises meant long shipboard medical practices con- 
ducted in isolation. Both the science and the technology 
of medical practice were underdeveloped. 

As medical specialization began to emerge in re- 
sponse to civilian scientific progress, the Navy adapted, 
offering short-term, general refresher courses to its 
medical officers. By 1930 sponsored study for six 
months, and occasionally for up to one year, was al- 
lowed in certain civilian hospitals, but in only a limited 
number of specialties. The dominating arguments 
favored severe curtailment of specialized preparation, 
regarding specialization as superfluous to the general- 
ist character of active-duty health care needs. 

As the Navy Medical Corps rose to 12,000 physicians 
during World War II, it was apparent that the skills, 
experience and capabilities civilian specialists brought 
to the Navy contrasted sharply with those of the general 
medical officer. In particular, the GMO showed a 
markedly limited ability to help patients recover from 
diseases or combat wounds. The compartmentalization 
of scientific principles and medical practice was appar- 
ent to even the most casual observer. In addition, the 
long duration of the war severely curtailed opportuni- 
ties to maintain and develop the health care skills 
required to provide comprehensive health care to a 
waiting civilian population. After demobilization, 
specialization and residency opportunities responded to 
that need. 

With the military medical experiences of the 1920 's 
and the 1930's in mind, Navy medical planners in the 
mid 1940's set the stage for the growth and develop- 
ment of a comprehensive health care system. The Navy 
and its sister services could ill afford anything less than 
complete health care capability. That capability is now 
unmistakably linked with increments in medical service 
to its personnel. 



10 



U.S. Navy Medicine 



Supported primarily by the physician draft, with its 
compulsions and complications, an in-house health care 
support system evolved. But as continuing dependence 
on draft-driven programs became a national issue in 
general, and a special issue within the Navy, it became 
necessary to develop alternative and dependable 
sources of medical officers with specialty skills and ex- 
perience. And as civilian medical departments ce- 
mented their reputation by sponsoring educational 
programs, so also did the Navy Medical Department. 

In recent years, a number of new but overriding 
issues have developed: shrinking assets, severe com- 
petition for Department of Defense resources, and a 
requirement to demonstrate exactly how much health 
care should be provided and at what cost. So the last 
phase of this abbreviated history can be called the era 
of consolidation, from which has come the require- 
ments-based Navy health care system. 

Table I shows the development of the Navy residency 
programs from their beginning in 1947, when about 9% 
of the Medical Corps was in training. By 1975 that had 
risen to 27%, which is what it is today when we have 
approximately 1,020 people in training. The fact that 
27% of the Medical Corps is in training at any one time 
is of particular concern to our critics. Each year, during 
the POM (programs objectives memorandum) cycle we 
have to justify that figure. 

TABLE I. Historical Perspective of Naval 
Residency Programs 





Corps 


Total number 


Total percent 


Year 


strength 


under training 


under training 


1947 


3451 


310 


9.00% 


1948 


2928 


392 


13.40% 


1949 


3235 


357 


11.03% 


1950 


2676 


306 


11.00% 


1951 


4532 


187 


4.12% 


1952 


4145 


218 


5.25% 


1953 


6157 


483 


7.84% 


1954 


3485 


153 


4.40% 


1955 


3355 


287 


8.55% 


1959 


3291 


472 
377 


14.34% 


1962 


3490 


10.80% 


1963 


3523 


391 


11.10% 


1970 


4524 


613 


13.55% 


1971 


4253 


610 


14.34% 


1972 


4450 


635 


14.27% 


1973 


3955 


676 


17.09% 


1974 


3403 


847 


24.89% 


1975 


3391 


931 


27.46% 



Military forces will continue to exist. Their mission is 
to plan and carry out national security policy, as 
directed by the President, through the National 
Security Council and the Joint Chiefs of Staff, and as 
implemented by the Department of Defense. It follows, 
then, that contingency planning must form the base for 
manpower and materiel requirements. Health care is 
an essential element in any such planning. 

Contingency planning in isolation, however, is in- 
herently wasteful: contingency forces must be effec- 



tively employed in the noncontingency period. It is 
therefore essential from the outset to comprehend the 
Navy health care support system in its two major orga- 
nizational and philosophical configurations. 

The defense program and planning guidance (DPPG) 
memorandum— of which you will hear a great deal this 
week — defines the primary mission of the military 
health care system: to provide medical support 
necessary to assure combat readiness and conserve 
military fighting strength in time of war. Resources 
may be programmed to provide care and treatment of 
other than active-duty members in certain situations; 
these include (1) if adequate health care facilities are 
not available, such as overseas or at underserved 
locations; (2) if the cost of treating dependents and 
retirees in military facilities is less than the alterna- 
tives; or (3), and this is important for us, if a valid 
teaching or training requirement is being met. We con- 
sider this guidance to be directive. 

In peacetime, the civilian health care support system 
is essentially a societal model based on sociopolitical 
and economic determinants, influenced by any number 
of different forces. In a period of conflict, the civilian 
health care support system converts to a mixed national 
security/societal model which tries to balance all these 
impacting influences to achieve the best possible 
results in providing essential health care to the nation. 

In a wartime situation, the military health care sup- 
port system converts to a purely military model based 
on projections of health care requirements in combat. 
Requirement is defined as ' 'that without which the job 
cannot be done." The degree to which requirements 
are not matched by capability is a shortfall. 

In peacetime, the military health care system is a 
mixed military/societal model based on the need to 
employ our contingency forces as directed by the 
DPPG. This health care support consists of inpatient 
care, preventive medicine, planning, and logistics. All 
four components operate at the same time, but in 
peacetime the most visible component is our direct in- 
patient care. 

This peacetime military health care support system is 
limited by monetary constraints. The Office of Manage- 
ment and Budget, through its authorization and appro- 
priations process, reviews the submissions of the Exec- 
utive Branch and the Congress. 

The balanced program, mandated by the DPPG, 
requires a specialty mix of Medical Department person- 
nel who will also form the deployment force during a 
national emergency. The specific manpower require- 
ments for that initial contingency response force should 
serve as the base for our training requirements. As this 
manpower pool is also the nucleus of contingency medi- 
cal support, it generates the coercively logical and 
DPPG-directed requirement that all medical officers be 
trained in the military aspect of their medical specialty. 
Such training is a continuing requirement, one that will 
be incorporated into all our training programs and con- 



Volume 68, January 1977 



11 



TABLE II. Specialty and Numbers of Programs in Graduate Medical Education 1977-1978 Training Year 



Facility 



Camp Pendleton 

Charleston 

Jacksonville 

Pensacola 

Bethesda 

Oakland 

Portsmouth, 

San Diego 



Va. 



FamPrac 



Total 35 



OB/GYN 



16 



?eth 



Peds 



10 



16 



Psych 



11 



BasMed 



OpMed 



21 
17 
18 
32 



88 



13 
13 
13 
16 

55 



BasSurgery Total 



9 

9 

9 

8 

47 

41 

48 

65 

236 



tinuing education programs. So, in the event of contin- 
gency, all medical officers will have jobs for which they 
are prepared. 

This essentially straightforward approach is often 
complicated by conflicting demands generated by the 
services, the Department of Defense, the Office of 
Management and Budget, and the Congress. The 
degree to which we accommodate these competitive 
imperatives will determine our effectiveness. But, 
remember, the way we view our own performance is by 
no means the way our performance is viewed by our 
confreres and our critics. 

Our training program, then, is predicated on this 
basis: the number of people in training at any given 
time is derived from the difference between designated 
requirements and available assets. The specialty mix is 
determined by balancing the program requirement. 
People trained in these programs must be able to per- 
form in contingency and noncontingency situations. 

Faced with the specialty deficit we know we are going 
to have, and with what we know of the recruiting 
picture, does anyone really think the military doesn't 
need to train medical officers? Does anyone really 
doubt that cancelling graduate medical education 
would take us back to the 1920's? Would the American 
public tolerate that? 

There is massive misunderstanding about graduate 
medical education in the U.S. Someone called me 
recently after reading an Institute of Medicine report 
that said more general surgeons were being trained in 
the U.S. than were needed. My caller wanted to know 
why, if that was true, the Navy and the other military 
services were training general surgeons. He had not 
appreciated the fact that no matter how many general 
surgeons are being trained not all volunteer to join the 
Navy. And to the degree that we require general sur- 
geons and are not obtaining them as volunteers, we 
must train them. 

As a result of the work done in previous SAC ses- 
sions, we have taken certain initiatives in our graduate 
medical education structure. The training requirements 
break down into four categories: we must define the 
requirement, compare it with present assets, identify 
any shortfall, and train enough people to close the gap. 

Beginning in 1977 the Navy will offer 236 first-year 
(level 1) graduate medical education positions, in eight 



TABLE III. Residencies/Fellowsh 


ps in Naval Activities 




Number of positions 


Specialty 


each year 


Aerospace medicine 


6 


Anesthesiology 


18 


Anesthesiology research 


1 


Dermatology 


,f 


Family practice 


35 


Hand surgery 


3 ? 


Internal medicine and subspecialties 


Cardiovascular disease 


4 


Clinical immunology and allergy 


1 


Endocrinology and metabolism 


2 


Gastroenterology 


3 


Hematology /oncology 


4 


Nephrology 


1 


Pulmonary disease 


4 


Neurology 


3 


Nuclear medicine 


3 


Obstetrics and gynecology 


16 


Gynecologic endocrinology 


1 


Maternal and fetal medicine 


1 


Occupational medicine 


1 


Ophthalmology 


8 


Orthopedic surgery 


12 


Otolaryngology 


8 


Pathology 


10 


Pediatrics 


16 


Plastic surgery 


1 


Preventive medicine (general) 


11 


Psychiatry 


Radiology 


14 


Surgery 


12 


Peripheral vascular surgery 


1 


Surgical research 


1 


Thoracic and cardiovascular surgery 


2 


Urology 


6 




Total 244 



naval hospitals. As shown in Table II, these positions 
will include programs in basic medicine, basic surgery, 
family practice, obstetrics and gynecology, pathology, 
and pediatrics. The basic medicine and basic surgery 
years will be broadly oriented, and will include four 
months of surgery, four months of medicine, and elec- 
tives appropriate to the trainee's anticipated clinical 
specialty. The family practice, Ob/Gyn, psychiatry, 
pathology, and pediatrics positions will conform to cur- 
rent guidelines for categorical programs. Trainees in 
basic medicine will be prepared to enter advanced 
training in anesthesiology, dermatology, general 
internal medicine, neurology, ophthalmology, and 
radiology. Trainees in basic surgery will be prepared to 



12 



U.S. Navy Medicine 



enter advanced training in general surgery, otolaryn- 
gology, orthopedics, neurology and neurosurgery. 

Implicit in this plan for Navy- sponsored postdoctoral 
medical education is the likelihood that most first-year 
trainees will serve a tour as a primary care medical 
officer immediately after they complete their first year 
of graduate medical education and before they begin 
further advanced training. 

These modifications are essential to meet the Navy's 
worldwide requirements for high-quality primary 
health care. But the changes do not exclude physicians 
from advancing into available clinical programs of their 
choice. After a period of service in primary care, physi- 
cians will have maximum opportunity to enter specialty 
training. 

This change in our level 1 graduate medical 
education program has been submitted to the Liaison 
Committee on Graduate Education of the American 
Medical Association for review. The Committee will 
follow our progress with interest. 

The change represents an interruption in the con- 
tinuum of graduate medical education. It is not a free- 
standing internship: there is a very real difference. We 
have informed all our training program chairmen of 
these changes, and will incorporate the changes into 
our specialty training programs to satisfy AMA require- 
ments for graduate medical education programs. 

Our follow-on training programs are shown in Table 
III. There are 35 specialty and subspecialty programs, 
located at all our major hospitals. We are not 
vulnerable to the charge that we use training programs 
to justify maintaining marginally productive facilities. 
Rather, as our workload diminished in Boston, St. 
Albans, and Great Lakes, for example, we quickly 
closed our training programs there. We are also 
phasing out our training programs at Naval Regional 
Medical Center Philadelphia. 

This assault on graduate medical education is not 
confined to the military. There are at least two reports 
suggesting curtailment of civilian graduate medical 
training programs, and calling for a reorientation to 
what are perceived as national requirements. The In- 
stitute of Medicine's report on reimbursement policies 
for Medicare and Medicaid suggested to the Congress 
that all specialty training programs should be frozen at 
the number of positions available on 1 July 1975, 

Many people high in the Government wish to make 
medical schools charge students enough tuition to cover 
all expenses. If it costs $14,000 a year to train a medical 
student, then the student should be charged $14,000 a 
year. The goal is to remove government subsidies from 
the medical schools and then to increase scholarships 
so the number of medical school students will not drop. 
From the medical school standpoint, this is an attrac- 
tive administrative tool. But I believe it is a gross error 
in social policy. It allows the budget specialists to 
determine who will practice which medical disciplines, 
where they will practice, and how many will be allowed 



to practice — all under the premise of achieving a better 
distribution of medical care in the U.S. 

This is simply the latest attack. What the result will 
be, I do not know. But I think we can safely say that we 
are not out of the woods. We have been promised that 
training will be a major issue in this year's budget 
cycle. Training was also a major issue last year. As 
Admiral Cox indicated, we have taken a $12 million cut 
in training in the last three years. We cannot take 
another $12 million cut and remain viable. 

The issue now is, How do we survive with graduate 
medical education? I think we are in a reasonably good 
position because we can relate our requirement for 
graduate medical education to manpower require- 
ments. And to the degree that we can relate our man- 
power requirements to a contingency requirement, we 
can justify our graduate medical education programs. 

Manpower: 

The Requirement Base 

RADM E.J. Rupnik, MC, USN 

Assistant Chief for Human Resources and Professional 

Operations, BUMED Code 3 

The old saw that "money makes the mare go" is not altered 
when the mare is substituted for by a tank or an atom bomb. 
Following each war there is a tremendous resurgence of feel- 
ing against the military. This now expresses itself in various 
investigations, in charges hurled back and forth, in loud com- 
plaints about "caste systems," food and discipline, and even 
in severe criticism of the prosecution of the war, despite its 
success. This tumult and shouting will die; unfortunately, it 
probably will be replaced by tight budgetary purse strings. 
Names will never hurt us, but tight purse strings may choke 
us into professional marasmus. The argument, as far as the 
Medical Corps is concerned, is not whether there should be 
an Army, Navy or Air Force; it is not what is the effective 
fighting force. Our position is that as long as there is an 
Army, or a Navy or an Air Force, it must be composed of men 
and these men are entitled to the very best of care. To this 
end, all associations which are interested in military medicine 
should exert every possible effort to see that adequate funds 
are provided for its future development. 

That quotation is taken directly out of an address by 
CAPT George Raines, chief of neuropsychiatry at 
Bethesda, at a meeting of the Association of Military 
Surgeons in Detroit 30 years ago\ Some problems never 
leave us: the names and the faces change, but the old 
problems seem to hang around. As I read those words, I 
can't help but think of how appropriate they are today. 
There have been a lot of good people who have come 
and gone in those 30 years, but we seem to be stuck 
with the same old problems. The proposed solutions 
(and there have been many) have only been temporary. 

Most of you are aware by now that within the past 
few months Dr. Robert Smith was appointed as Assist- 



Volume 68, January 1977 



13 



ant Secretary of Defense for Health Affairs. A few days 
after he took office I had the privilege of briefing him on 
the problems which beset our Navy Medical Depart- 
ment today, I started out by making two observations: 

1) The all -volunteer force idea is not working for the 
Navy Medical Department. 

2) We have, during the interbellum periods, been 
unable to balance the resources provided to us against 
the demands placed on our health care facilities. 

With regard to the all -volunteer force, our real 
medical officer problems began when the doctor draft 
was abolished. With the draft we had a generous 
supply of general medical officers to fill many of our 
operational billets. Many medical officers, in order to 
avoid duty as a GMO with the Marines or aboard ship, 
volunteered for flight surgeon training and undersea 
and diving medicine training, so we had little difficulty 
filling all types of operational and non-BUMED- 
managed facility billets. Those are the areas where we 
have the greatest difficulty finding recruits today who 
are either interested or, if interested, qualified. 

With regard to our inability to balance our resources 
against the demands placed on our health care facili- 
ties, the situation we face is reflected in the data in 
Tables I, II, and III. The total number of active-duty 
Navy and Marine Corps personnel in FY69 was slightly 
over one million (Table I). Since then it has dropped to 
approximately three-quarters of a million. In FY69 the 
number of dependents of active-duty personnel were 
979,000; in FY76 there were 848,000. There were 
241,000 retirees in FY69, and 337,000 in FY76. Most 
important, we had 651,000 dependents of retired per- 
sonnel in FY69, and 906,000 in FY76. If you look at the 
total, there is not a lot of difference; yet we are given 
the same or less resources to do the job. 

Table II shows what has happened to our officer 
strength. And remember, our Medical Department 
strength is based on the overall Navy strength. The 
total number of Navy officers in FY69 was 85,687. By 
FY76 that had dropped to 64,240— a decrement of ap- 
proximately 25%. We had a similar drop in Medical 
Corps officers. Note that this is an end strength; it is 
not billets. It's the average on-board strength, and 
that's the only thing you can really compare. 

Now the line thinks we are getting a break. They had 
to go down 25%, while we only dropped 22%. But with 
our reduced resources we have to take care of the same 
workload we had back in 1969. And the same goes for 
the Dental Corps, the Medical Service Corps, and the 
Nurse Corps. Their reductions aren't as drastic, but 
they are significant. The picture among our enlisted 
personnel is essentially the same (Table III). 

CAPT Raines was right when he predicted 30 years 
ago that after the tumult and shouting the purse strings 
would be tightened. They were. It was during the era of 
Louis Johnson that we almost fell into professional 
marasmus. Korea came along and once again we were 
bailed out. 



TABLE 1. Navy Beneficiary Population 






FY69 


FY 76 


Active-duty Navy/Marine Corps 

Dependents of active-duty 

Retired 

Dependents of retired* 


1,071,000 
979,000 
241,000 
651,000 


727,000 
848,000 
337,000 
906,000 


Total population 


2,942,000 


2,818,000 



'Beneficiary figures for FY69 do not agree with Congressional 
submit. FY74 actual semiannual counts were conducted for first 
time. FY69 adjusted to reflect factors based on actual counts. 

TABLE II. Officer Average On-Board Strength 



Total Navy 
Medical Corps 
Dental Corps 
Medical Service Corps 
Nurse Corps 


FY69 

85.687 
4,738 
1,901 
1,642 
2,408 


FY76 

64,240 
3,688 
1,775 
1,753 
2,542 


Change 

-25% 

-22% ; 
- 7% 
+ 7% : 
+ 6% 



TABLE III. Enlisted Average On-Board Strength 



Total Navy enlisted 

Hospital corpsmen 
Dental technicians 



FY69 

666,700 
31,311 

4,035 



FY76 

460,808 

24,280 

3,858 



Change 

-31% 
-22% 
- 4% 



But what is happening now? In reducing the Navy 
Medical Department budget by $10 million in fiscal 
year 1976, the House Appropriations Committee said: 

For the last two years the Committee held in-depth hear- 
ings on the medical programs of the Department and made 
several suggestions for improved operations in the hope of 
reducing costs. Information obtained by the Committee this 
year indicates that improvements are moving very slowly. . . . 
While costs are increasing, military hospitals continue to be 
operated at less than half of the normal bed capacity. Also, 
the request for CHAMPUS is increased by over 10% of the 
original amount provided for FY 1975 and, based upon infor- 
mation provided the Committee, is expected to increase by 
over 20% before the end of FY 1976. Yet the dependents of 
active-duty military personnel continue to consume about 
40% of CHAMPUS funds while military medical facilities 
remain substantially unused. The Committee has stated in 
prior years and again emphasizes that this does not indicate a 
prudent management of medical operations. Thus, it is re- 
ducing the funds requested with the objective of obtaining 
better management of medical funds provided. The Commit- 
tee does not believe it prudent to provide large increases in 
funding when utilization of funded military facilities is 
declining. 

The Committee report was dated 25 Sept 1975, and it 
is a matter ofrecordl At that time we were already one- 
quarter through FY76. By the time the Bill was passed 
and BUMED and the Navy initiated action to offset 
reduced operations, the fiscal year was almost half 
over. That meant the $10 million reduction had to be 
taken in the last six months of the fiscal year. Since over 



14 



U.S. Navy Medicine 



$8 million of the $17 million increase in the BUMED 
budget from 1975 to 1976 was for mandatory increases 
(pay raises, drug abuse, etc.), this left only an $11 mil- 
lion increase to absorb the Congressional reduction. 
This amount was barely enough to cover the high rate 
of inflation for medical supplies in 1976. The net result 
was an actual decrease in purchasing power between 
fiscal years 1975 and 1976, all of which had to be accom- 
plished in the last six months. 

The rationale of Congress was paradoxical— direct- 
ing us to improve management by bringing CHAMPUS 
patients into military hospitals while at the same time 
providing what amounted to fewer dollars. They even 
helped provide the increased number of patients by 
extending the CHAMPUS nonavailability statement 
radius from 30 to 40 miles. What the Committee failed 
to realize in their referral to the 50% bed occupancy is 
that beds do not take care of patients, people do. People 
do, provided they are given sufficient resources, 

The effect upon the Navy Medical Department was 
devastating. Civilian personnel dropped about 1,000 
below ceiling, a loss of about 10%. All special programs 
were cancelled. Three million dollars was cut from the 
maintenance program (about 17%). Administrative 
services were cut to the bone, attendance at profes- 
sional meetings was drastically reduced, equipment 
replacement was deferred, and occupational health pro- 
grams were reduced. Can anyone dispute the adverse 
effects these actions must have on the quality of the 
health care delivered? 

The transitional quarter budget was cut $3 million 
based on the same rationale, ensuring that there would 
be no recovery during that period. The FY77 budget is a 
bare bones budget which will not allow recovery from 
the effects of the 1976 and transitional quarter draw- 
downs. 

What I've just told you is a fact, and we have to learn 
to live with it. You've heard this before and you're 
going to hear it again and again: "Things are going to 
get worse before they get better" and "You're going to 
have to do more with less. ' ' 

There is one ray of light in this dark picture. The law 
under Title 10, U.S. Code, Chapter 55, Section 1076,' 
paragraph C, provides that the commanding officer of 
health care facilities will determine whether categories 
of patients other than active-duty will be denied care, 
depending on the adequacy of the commanding 
officer's resources to carry out the primary mission. 

Until a few weeks ago we had no precise definition of 
our primary mission. Now we do, and each facility has 
been made aware of this primary mission. Can we use 
this as a lever to force those in higher authority to give 
us added resources? Or failing that, can we force them 
to support us in denying health care in our facilities to 
the low-priority beneficiary? If we accomplish the 
latter, is it not ultimately self-defeating, since we will 
ourselves limit the proper patient mix to a point that 
will make clinical practice in the Navy professionally 

Volume 68, January 1977 



unrewarding? I don't have answers to any of those 
questions. But it appears to me that whether we find 
answers or not, the various study groups — including 
the Office of Management and Budget, General Ac- 
counting Office, the Congressional investigative staff, 
and even our own "line"— are determined to reduce 
our Medical Department and find other health care 
systems through which care can be provided to the low- 
priority beneficiary. 

None of the foregoing statements appear to address 
the topic I was assigned: "Manpower: The Require- 
ment Base." I don't think that any of you would deny 
me the privilege of saying what is on my mind at this 
stage in my career. The fact is that with all these 
studies going on, I'm not sure what the requirement 
base will ultimately be. There is no doubt in my mind 
that for the immediate future our total numbers are tied 
to the line, and as their numbers go down, so will ours. 
In the final analysis, the line numbers will determine 
our requirement base. To that end, we are committed to 
redistribute our medical officer billets based on factors 
which take into consideration the active-duty popula- 
tion, the remoteness of the activity, the extent to which 
an activity is engaged in training, and the documented 
productivity of that activity. Following that redistribu- 
tion, if a billet does not exist, a body will not be ordered 
in. That's the "no billet, no body" concept. 

We have problems in the other communities but they 
are not nearly as critical as the Medical Corps so I will 
not dwell on them. The size of the Medical Corps and 
the size of the beneficiary population we are expected 
to take care of will determine the size of the other corps. 
It must be obvious to all of you that right now we do not 
have enough nurses or corpsmen to support the medical 
officers currently in the Navy. 

There are a number of other problems that 1 pre- 
sented to Dr. Smith, and time really doesn't permit me 
to review them in any detail. But I would just like to list 
them for you, to stimulate your minds a little. 

The distribution of medical officers I've covered a 
little, but I didn't cover the long-range solution. Bob 
Strange will probably get into some of those areas. 

Then there is the problem of the increased sophisti- 
cation of our health care delivery system, and the 
problem of budgetary cuts which reflect a de-emphasis 
on clinical research, on the Clinical Investigation Pro- 
gram. You've already heard about the severe con- 
straints on our training program. 

We have some fears about our scholarship program 
—the same fears we had when we required people to 
fulfill a period of obligated service after residency train- 
ing. This was considered indentured servitude and was 
repugnant to the physicians forced to serve out that 
period of time. I fear that our scholarship students may 
feel the same way in the future years. Only time will 
tell. 

A tighter budget means less money for continuing 
medical education but I think the Surgeon General will 

15 



be able to turn that around. Recruiting is another big 
worry, as is the program budget decision that cancelled 
our physician's assistant training. That decision was 
made by a group of analysts who consulted us only after 
the fact. They tell us we can have PAs, but we can't 

train them. 

The outcome of the OMB-DOD-HEW study is still up 
in the air and having a serious effect on Medical De- 
partment morale. So is another OMB study that makes 
unpalatable recommendations regarding variable in- 
centive pay. 

In addition to all that, we have been asked to provide 
medical and dental officers to the Coast Guard at a time 
when we can't keep our own operational billets filled. 

We have not been able to resolve the corporate limit 
problem. If you travel from one place to another, under 
the law you are entitled to reimbursement for the 
travel. But most of you in this room have come here on 
your own, out of the goodness of your hearts, without 
reimbursement. How big can our hearts be? 

There's also the problem of reduced optometry ser- 
vices, another program budget decision made by the 
analysts based on limited information, and further 
eroding health care benefits to the total beneficiary 
population. 

Then there's the Uniformed Services University ol 
Health Sciences billet problem. We were told that the 
billets were given to us, but they weren't. They were 
taken out of our hide, When we asked that the billets be 
restored, our request was caught up in bureaucratic red 
tape and has yet to be untangled. I don't know what the 
result will be. 

We've also had to take funding decrements for the 
shore establishment reduction candidates. For ex- 
ample, the 1978 budget was based on a reduction of 
several facilities. But it looks as if some of those facili- 
ties may be maintained at their present capacity or at 
only slightly reduced capacity. Nevertheless, we have 
lost the resources to support them. That means we've 
got to take resources away from all of you to help these 
other places survive. 

You are all familiar with the prayer: "God grant me 
the serenity to accept the things that I cannot change; 
the courage to change the things that 1 can; and the 
wisdom to know the difference." I hope we all have the 
wisdom to know the difference. 

Medical Corps Manpower 

CAPT R.E. Strange, MC, USN 

Director, Medical Corps Division, BUMED Code 31 

You have been hearing about the unpredictable and 
frequently unpleasant winds that buffet us. It reminds 
me of the ancient Chinese folk tale about the farmer 
whose horse ran away. That evening the neighbors 



16 



gathered to commiserate with him about such bad luck, 
but the farmer only said, "May be." The next day the 
horse returned, and brought with him six wild horses. 
The neighbors came around rejoicing about the 
farmer's good fortune, and the farmer again said, 
"Maybe." 

The next day the farmer's son saddled one of the wild 
horses and tried to ride him, but he was thrown and 
broke his leg. That night the neighbors all came to 
express their sympathy on this misfortune, and the 
farmer said again, "May be." 

But then the next day the emperor's men came to the 
village to seize the young man for conscription into the 
army, and because of his broken leg the young man was 
unable to go. He was excused, and the neighbors came 
to say how fortunately the whole affair had turned out. 
Of course the farmer once again said, "May be, may 

be." 

Now, we are indeed beset with difficulties, but some- 
times good things happen. It is easy to ricochet be- 
tween euphoria and despair, but usually our euphoria 
turns out to be unwarranted, and the despair un- 
founded. The only tenable and practical attitude I have 
been able to develop is what we might call "optimistic 
skepticism," or if you prefer, "skeptical optimism"— 
withholding judgment and emotionalism. In other 
words, saying "May be, may be." 

Table I shows Medical Corps strength, losses, and 
gains in recent years. The 37% gain in 1972 is mislead- 
ing. That was a year when a lot of people who had been 
deferred through the Berry Plan came in. Except for 
this red herring our gains stayed about the same while 
our losses generally increased. In FY75, our loss rate 
dropped to 30% and we had a 30% gain to balance it for 
the first time in years. In FY76 we had a 27% loss rate 
balanced by a 27% gain. This type of balance began in 
FY75— the year variable incentive pay went into effect. 

Table II shows where Navy physicians are coming 
from. As everyone knows, the Berry Plan is precipi- 
tously declining. The startling numbers are for 
volunteers: we will need 335 Medical Corps volunteers 
in FY77 to maintain our strength, and there is just no 
way we are going to get that many. The most we have 
been able to recruit in one fiscal year is around 180. 
Consequently, we are going to have some shortfalls. If 
we recruit 200 medical officers in each of the next fiscal 
years— and since 180 has been our best result so far, 
that is an optimistic estimate— we will still be short 135 
physicians at the end of this fiscal year and short 272 
physicians at the end of FY78. 

Table III shows what has happened to the community 
in which our employers— the line— are most interested. 
Nobody in the line ever asks for a heart surgeon or a 
child psychiatrist: the line wants general medical offi- 
cers, flight surgeons, submarine medical officers— and 
you can see what has happened to those groups. In 
FY73 our total strength was 4,345 medical officers, with 
1,752 physicians in the group which includes GMOs, 

U.S. Navy Medicine 



TABLE I. Medical Corps Strength/Losses/Gains 



Fiscal 


Begin 




Year 


Strength 


Losses 


FY71 


4524 


1436 


FY72 


4253 


1381 


FY73 


4450 


1539 


FY74 


3955 


1552 


FY75 


3403 


1015 


FY76 


3431 


930 



% 


Gains 


% 


32 


1165 


26 


32 


1578 


37' 


35 


1044 


23 


39 


1000 


25 


30 


1043 


30 


27 


929 


27 



Large number of accessions from Berry Plan who entered pro 
am at height of Vietnam conflict (1967-68). 



TABLE II. Medical Corps Accessions 



Fiscal 


End Sc 


Year 


Strength P 


FY75 


3431 


FY76 


3447 


FY-TQ 


3771 


FY77 


3640 


FY78 


3613 



Scholarship 
Programs 



231 
238 


209 
181 



*Needed to maintain end strength 



Berry 

Plan 



518 
416 
235 
129 
32 



Volunteer* 



159 
171 
180 
335 
337 



gram 



TABLE III. General Medical Officers, Flight Surgeons, 
and Submarine Medical Officers 



I Community 



FY73 FY74 FY75 FY76 Decrease 



Total 2100 

community 
GMO* 



4345 
1752 



3971 
1125 



3836 3848 
708 657 



11.4% 

62.5% 



i GMO/Totat Medical 
Corps ratio 



40% 28% 



18% 17% 



"General medical officers + flight surgeons + submarine medical 
otticers 



flight surgeons and submarine medical officers. Opera- 
tional people and general medical officers made up 
40% of the Medical Corps. This past fiscal year our 
strength fell to 3,848 physicians, with only 657, or 17% 
of the Corps, in this group. Overall, the number of Navy 
physicians has declined 11.4% since FY73, but the de- 
crease in the operational medicine and GMO communi- 
ties has been about 63%. That's one of our major prob- 
lems, 

Where are our physicians assigned? Table IV shows 
the distribution of medical officers other than flight 
surgeons. Of the billets belonging to the Commandant 
of the Marine Corps, only 41% are filled— and that's 
not including flight surgeons. 

Last March about 92% of CINCLANTFLT billets 
were filled, and about 90% of CINCPACFLT billets. 
The total percent of operational billets filled as of last 
March was about 76%, again not counting flight sur- 
geons. And remember that those billets belong to the 
line, not to the Bureau of Medicine and Surgery. 

Authorized billets for the Chief, BUMED at that time 
(not including flight surgeons) were about 2,700, and 
were 116% filled. The difference between 116% and 
76% is thrown up to us every time we meet with line 
commanders. It's a problem with which we struggle 
continuously. We know why we have more doctors in 
our hospital facilities than we have with the fleet, but 
we can't excuse it. We are trying to correct it. 

Table V shows the distribution of flight surgeons, 
who are one of our hottest commodities with the line! 
As of last March only 43% of the Marine Corps flight 
surgeon billets were filled, while CINCLANTFLT had 
72% filled, and CINCPACFLT had 71%. In all, only 

Volume 68, January 1977 



TABLE IV. Medical Officer Manning, Less Flight Surgeons 
31 March 1976 



Claimant 



Author- 
ized 



On- 

Board 



Differ- 
ence 



% of On- 
Board to 
Authorized 



CMC 

CINCLANTFLT 
CINCPACFLT 
Other 



161 
82 
80 
70 

Subtotal 393 



CO A* 

CH BUMED 

Unassigned 



265 

2665 

0_ 

Total 3323 



66 
75 
79 
78 

298 

29 

3100 

73_ 

3500 



-95 

- 7 

- 1 
8_ 

-95 

-236 

435 
+ 73 



40.99% 

91.46% 

93.75% 

111.42% 

75.82% 

10.94% 

116.32% 




+177 105.32% 



•Central Operating Account (includes transients, prisoners, etc.) 
TABLE v - Flight Surgeon Manning, 31 March 1976 



Claimant 


Author- 
ized 


On- 

Board 


Differ- 
ence 


% of On- 
Board to 
Authorized 


CMC 

CINCLANTFLT 
CINCPACFLT 
Other 

Subtotal 

COA* 

CH BUMED 

Unassigned 

Total 


61 
44 
52 
27 

184 

21 

151 



356 


26 
32 
37 
18 

113 



80 



193 


-35 
-12 
-15 
- 9 

-71 

-21 

-71 



-163 


42.62% 
72.72% 
71.15% 
66.66% 

61.41% 



52.98% 




54.21% 



"Central Operating Account (includes transients, prisoners, etc.) 



61% of our flight surgeon billets were filled. Obviously, 
fewer flight surgeons were assigned to BUMED activi- 
ties. 

The total situation— flight surgeons, operational 
medical officers, and physicians at BUMED activities- 
is shown in Table VI. Our operational billets are about 
71% filled; our BUMED billets are about 113% filled. 
The two biggest areas where we desperately need 
people to keep our bosses happy are aviation medicine 
and Fleet Marine Force. 

From these data it is easy to see that our primary 
problem is maintaining a sufficiently large number of 
physicians. We have a problem in simply having 

17 



TABLE VI. Total Medical Officer Manning 
31 March 1976 



Claimant 



Author- 
ized 



On- 

Board 



Differ- 
ence 



% of On- 
Board to 

Authorized 



CMC 

CINCLANTFLT 
CINCPACFLT 
Other 

Subtotal 

COA* 

CH BUMED 

Unassigned 



222 

126 

132 

97 

577 

286 

2816 





Total 3679 



92 
107 
116 

96 

411 

29 

3180 
73 

3693 



-130 

- 19 

- 16 

_- 1_ 

-166 

-257 

364 

73 

+ 14 



41.44% 
84.92% 

87.87% 
98.96% 

71.23% 

10.13% 

112.92% 


100.38% 



♦Central Operating Account (includes transients, prisoners, etc.) 



enough medical officers, even before we even get into 
the problem of the right mix of medical officers. 

We also have a problem determining our real re- 
quirements—who and what is required to accomplish 
our mission. Our requests must be based upon contin- 
gency planning, and that's not easy. We have to deter- 
mine how our physicians will be distributed. RADM 
Rupnik talked about the study under way in this area. 
We have come up with a preliminary formula, the first 
part of which considers the active-duty population, be- 
cause the reason for our existence is to care for active- 
duty personnel. By allowing one medical officer for 
every 1,000 active-duty personnel (a traditional ratio 
whose origin is lost in the mists of antiquity), we have 
the first cut in the distribution of medical officers. 
Everywhere there are 1,000 active-duty personnel, we 
will place one medical officer. 

After that, we figure workload. Obviously, the more 
work people are doing the more doctors they should 
have: it is a built-in incentive system. 

Other considerations— training programs, isolated 
duty stations, and so forth— then come into play. 
After all this is done and we decide how many physi- 
cians should be located in each place, we then reassign 
the billets and eventually get bodies and billets lined 
up. Right now we have places where there are no billets 
and many bodies, and places where there are no bodies 
and many billets. We have to resolve this. 

Achieving the proper mix of medical officers is even 
more confusing. We have tried to categorize our facili- 
ties as to which are or should be primary care, second- 
ary care, or tertiary care facilities. We define primary 
care as care given at the point of access into the health 
care system; it includes primary care specialties. 
Secondary care comprises other basic specialty care, 
and tertiary care features the subspecialties. 

Our big problem, of course, is in primary care— the 
access point into the health care delivery system. If we 
include the usual designations of primary care 
specialists, plus a few general physicians, we have 
about 33% of our Medical Corps engaged in some sort 



18 



of primary care activity. The American Medical Asso- 
ciation says, and our studies also indicate, that we 
should have about 50% of our Corps in primary care 
specialties. So there has to be some overall realign- 
ment. 

As I said earlier, we have big problems with opera- 
tional medicine. We've made advances here by pooling 
physicians, by trying to redesignate some Marine 
Corps billets so the physicians can work in medical 
centers, and by using scholarship graduates for opera- 
tional duty. By these methods, we hope eventually to 
solve the problem of providing the primary operational 
care that our bosses are demanding of us, and that we 
should be delivering. 

There are also several personnel issues— variable in- 
centive pay, promotions and service obligation, for 
example— which affect our ability to recruit and retain 
physicians. 

Variable incentive pay has been extended by law 
until October 1977, and we assume it will continue 
beyond, that date. There are many studies under way to 
study variable incentive pay and the whole problem of 
pay for federal physicians, and there are many ideas 
about it. Some people think all federal physicians 
should get the same amount of money, others think 
physicians in administrative jobs should be paid very 
little while those who are seeing patients should receive 

alot ■ v, •**. 

This year we have had a major problem with 

obligated service for senior medical students, all 
because we decided to be consistent. That seems like a 
noble goal, but the morass we entered was amazing: 
obligated service is a quagmire of assorted instruc- 
tions, contracts, promises, and opinions. The Depart- 
ment of Defense has prepared a new obligated service 
instruction which should clarify a lot of misunderstand- 
ing. A simpler, more direct, and clearer directive about 
service obligations will be very helpful. 

One of the things which has concerned us most this 
year has been a massive change in promotion policies. 
The change was initiated by a new Department of 
Defense instruction which, to summarize, changes 
promotion opportunity to 0-5 and 0-6. In the past, each 
medical officer had a 90% chance of being picked for 
commander and captain, but this has now been 
changed to 80% for commander and 75% for captain. 
Along with the decrease in opportunity, there will be 
some slowing of promotions. These are big changes 
and, unfortunately, a lot of people will be disappointed. 

There's one good thing about the change: A 
physician now has to be on active duty for over a year 
before he or she can be considered by the selection 
board. That is a positive change. 

Another change is that we can no longer recruit 
physicians at a grade above lieutenant commander. 
That has been our policy for the last year, but now it is 
law. If someone has 20 or 25 years of practice, he will 
still come in as a lieutenant commander. That could be 

U.S. Navy Medicine 



good, or it could be bad. As the Chinese farmer said, 
"May be, may be." We will have to wait and see what 
the effect is. 

What are the most significant overall trends and 
issues in the Medical Corps at this time? One is the re- 
quirement that training programs be based on contin- 
gency needs. This is called "contingency-based re- 
quirement planning," and you will be hearing more 
and more about it in the months ahead. 

Another is the absolute necessity to eradicate the 
fleet/hospital polarity which has plagued us for years. 
The Surgeon General feels strongly about eliminating 
this dichotomy and achieving one Navy Medical De- 
partment. 

Finally, we must develop a new Navy medical officer. 
In the Medical Corps of the future, medical officer 
career patterns will involve continuous interweaving of 
clinical care ashore and clinical care afloat, operational 
medicine and medical center duty. It must be that way. 
Careers may differ quantitatively in the relative 
amounts of each type of duty, but they must not differ 
qualitatively by assignment to one type of duty at the 
exclusion of all others. 

We need "ambidextrous" medical officers— people 
who can use both hands; people who, in fact, may be 
given two assignments simultaneously. They may be 
working in a hospital ashore, but will have an accom- 
panying assignment to operational units. That is my 
personal belief, but I feel that sooner or later it must 
come to this or we will not be able to justify the 
existence of a Navy Medical Corps. 

None of our problems is new. Variable incentive pay, 
for example, has been around for much longer than 
most of us realize. I recently found a splendid little 
paper in the Naval Institute Proceedings from Septem- 
ber 1929, written by a Commander Mann, a Navy 
physician. He pointed out that the Roman Navy had 
great difficulty obtaining physicians and so they re- 
sorted to double pay and emoluments. On inscriptions 
about the Roman fleets, the names of ship surgeons 
were always followed by the word "duplicarious," 
indicating their status of double pay. 

The original pay amounted to 450 denarii, which was 
soon increased to 600 denarii. And after the reign of 
Septimus Severus, the paychecks were increased to 
1,000 denarii in order to get physicians to go to sea. 
They also had specialists at sea: Galen reports, in fact, 
that when the Roman fleet deployed to Britain they had 
eye specialists aboard. 

The Republic of Venice in the 14th century had a big 
Navy, and physicians on all their galleys. Reports show 
that a man called Valparius, a Venetian Navy physician 
around 1320, was given an allowance for quarters and 
professional supplies, and permitted to draw three 
years' pay in advance, in addition to his salary. He was 
also granted a considerable sum of money as a dowry to 
marry off one of his nieces. We have not reached that 
point yet, but it may be coming. 

Volume 68, January 1977 



Operational Medicine Support: 
Another Look 

CAPTJ.J. Quinn, MC, USN 

Office of Deputy Director of Program Planning 

and Analysis, BUMED Code 02-1 

CAPT Joseph D. Bloom, MC, USN 
Chairman, Department of Internal Medicine 
Naval Regional Medical Center, San Diego, Calif. 

One of the major issues in military medicine today is 
the question of operational medicine. What is it? How 
does it differ from non-operational medicine? What are 
its unique properties? How do we train physicians in its 
mysteries? What service does it provide our Navy and 
our country? 

We understand that a group has recently undertaken 
to define operational medicine, develop and sell the 
postgraduate educational program for the specialty, 
and recruit candidates. Some of us believe these efforts 
have been poorly thought out, ineffectively tested, 
awkwardly articulated and emotionally defended. Vfe, 
therefore, propose to challenge the philosophical basis 
of operational medicine education and practice. We 
hope that, by so doing, vanity might be replaced by an 
honest debate and an exchange of ideas about the real 
operational world. 

Of some importance is the definition— a definition 
based on preventive versus curative medicine, clinical 
versus sea or battlefield medicine. Operational medi- 
cine is and must be the direct support of military 
operations to reduce morbidity and mortality of our 
fighting forces, and to assure the functional efficiency 
of those forces. This definition must be applicable in 
wartime and peacetime, and must be appropriate to 
traditional and advanced technologic weaponry. 

In support of traditional military operations, opera- 
tional medicine includes the problems of amphibious 
medicine, battlefield medicine, tropical medicine, cold 
weather medicine, mountain military operations, sea 
immersion, sea survival and casualty evaluation 
systems, design and operation of advanced technology, 
and man-machine adaptation. It includes aviation medi- 
cine, submarine medicine, diving medicine, ecology, 
hyperbaric physiology, and the biomedical problems of 
surface effect vehicles. 

It is important to view the chronology of some of the 
issues eventuating in our current reassessment of oper- 
ational medicine training and practice, Fleet demand 
for greater evidence of operational support is not a new 
revelation for this group. Neither is the burgeoning 
disparity between our postgraduate training programs 
and the direct delivery of health care to fleet com- 
manders. Fashions in medical education over the past 
decade have insisted on continuing education from 
medical school through board certification, and greater 



19 



degrees of subspecialty sophistication before a physi- 
cian is considered completely trained. Also, during our 
professional lifetime many traditional medical prob- 
lems have been solved. Nutrition, for example, can now 
be handled by the dietitian, and does not require the 
close attention of the physician. So, too, many biomedi- 
cal problems of man-machine adaptation have been 
solved by substituting technological advances for physi- 
cian-directed biomedical monitoring. Witness, for 
example, the impact of pressurized aircraft on aviation, 
the elimination of carbon dioxide narcosis by the C0 2 
scrubber, and the steady decrease in air embolism de- 
compression sickness. 

Above all, our reassessment of operational medicine 
is required by the identification of biomedical problems 
associated with new strategic, tactical and technologi- 
cal approaches and developments. It is neither appro- 
priate nor feasible to offer a complete inventory, but a 
few examples might include: 

• Alterations in biorhythms associated with rapid 
movement through time zones. 

• Tissue injury related to laser and microwave radia- 
tion. 

• Adaptation or resistance to psychological stress. 

• Thought control. 

• Undifferentiated fatigue, boredom and sleepless- 



ness. 



• The effects of environmental toxicity. 

• Rapid evacuation. 

• Medical in-service management, such as open heart 
surgery, renal dialysis, and tissue transplantation. 

In examining the effectiveness with which traditional 
operational medicine reduces morbidity and mortality 
and enhances fleet readiness, we must consider the 
measurable contributions of the flight surgeon and the 
submarine and diving medical officer, particularly in 
special examinations and treatments, biomedical re- 
search, and fleet liaison. Many elements of operational 
support are common to aviation, submarine, and diving 
medicine; these elements include physical examination 
for special duty, accident investigation, and participa- 
tion in the administrative and operational readiness 
inspection. There is a diminishing need for special 
examinations and treatment provided on a recurring 
basis in all operational medical areas. This reduction is 
due, in large measure, to standardization of proce- 
dures, allowing them to be carried out by technicians 
with only minimum medical training. 

The actual and potential impact of the operational 
medicine specialties on morbidity and mortality of 
active-duty personnel is diminishing, and is not nearly 
as effective as continuing advances in human engineer- 
ing design. Medical officer opinion is still required, 
however, in biomedical research of operational rele- 
vance, in fleet liaison, and to set physical examination 
standards. An individual cross-trained in the technolo- 
gies of operational medical support can fulfill require- 
ments as well as or better than we are doing now. 



20 



A central feature of our argument is the essential in- 
terface between clinical and operational medicine. We 
believe that separatism, remoteness, and antagonism 
and misunderstanding between these groups should be 
discouraged. It amazes and alarms us that such a posi- 
tion is not obvious— that it must be identified and de- 
fended, if such is the case. 

There are many examples of applicable operational 
medicine models, and fundamental questions in the 
physiology of medicine that need answering. Hypoxia, 
for example, is a critical problem for the high altitude 
flight crew in a disabled oxygen system, or in a sub- 
marine that has lost its oxygen regenerating capacity, 
or for the diver who has outdistanced his gas supply. 
But hypoxia is also a critical issue for the patient with 
extensive chronic obstructive lung disease, or the surgi- 
cal patient receiving general anesthesia, or the fetus 
during a complicated labor and delivery. The under- 
standing of hypoxia gained by the clinician, the flight 
surgeon or the diving medical officer is clearly applica- 
ble to other areas. 

A similar argument could be drawn for studying 
man's adjustment to hypercarbia. Closed-space en- 
vironments are subject to this biomedical hazard, as is 
the individual with respiratory failure. Adjustments to 
noxious stimulants are complicated. Their understand- 
ing demands a detailed knowledge of the lungs, kidney, 
pituitary-adrenal axis, calcium, metabolism, water and 
electrolyte balance, body pH, and cardiovascular func- 
tion. The exposure of active-duty personnel to hyper- 
carbia must be dealt with eruditely by physician and 
attendants on the rescue vessel as well as in the inten- 
sive care unit. Exposing a physician to hypercarbia in 
either of these environments will better prepare him to 
carry out all his military and medical responsibilities. 
This opportunity to observe applied physiology in clini- 
cal environments as well as environments unique to 
military operations is one of the real attractions of a 
military medical career. 

So we see an alternative to the future training and 
deployment of flight surgeons and fleet medical offi- 
cers. We propose that clinicians cross-train in the 
technology of all military medical environments. The 
career patterns of individuals so trained would allow 
them to take either of two paths: one choice would be 
alternating assignments between fleet and clinical bil- 
lets; the second choice is to alternate assignments to 
our biomedical research laboratories with fleet and 
commander-type assignments. We believe this flexible 
career pattern will be more attractive to fledgling physi- 
cians considering a career in the military, especially in 
operational medicine. 

We predict some difficulty gaining acceptance ot this 
concept by fleet commanders in the aviation, sub- 
marine, and diving communities. They have become 
accustomed to having their own flight surgeons, their 
summary medical officer, in short, their own doctor. 
With this change physicians will no longer wear wings 

U.S. Navy Medicine 



or dolphins. Furthermore, if there are irreconcilable 
differences of opinion within the Medical Department, 
selling such a proposition to our nonphysician ship- 
mates and line commanders may be impossible. Our 
task, then, is to agree on the most effective way to train 
and deploy scarce medical talent, and to convince the 
line commanders and the aviation and submarine com- 
munities of the benefits of the new approach. 

We believe that this approach— with its potential for 
breaking down barriers between operational medicine 
and clinical medicine— will benefit the naval medical 
officer who does not identify with operational medicine. 
Early cross-training in operational and clinical disci- 
plines and subsequent alternate assignments between 
operational and clinical billets will better mix and stim- 
ulate all naval medical officers, whether they are opera- 
tionally or clinically oriented. 

In our Navy Medical Department organization, this 
change should mean the disestablishment of separate 
submarine and aviation medicine organizational enti- 
ties within the codes of operational medical support. 
One suggestion is that realignment within the code will 
emphasize biomedical research requirements, setting 
of physical standards, accident investigation, billeting, 
and fleet liaison. In naval regional medical centers, the 
change should mean that operational medicine branch- 
es will be established within the departments of inter- 
nal medicine and general surgery. These new branches 
should be charged with an operational medical role, 
such as training and use of hypobaric and hyperbaric 
chambers within the region, evaluation of new 
technologies in wound management, casualty evacua- 
tion, and support of large fleet exercises, to include 
involvement in regional tertiary care centers. 

We recognize the need for a small cadre of Navy 
physicians to orientate their careers toward deep 
involvement in operational medicine. We believe this 
need can best be met, however, by giving this select 
group alternative training tracks rather than by de- 
manding their premature and sometimes unwise early 
commitment to a single option. Remember that morbid- 
ity and mortality during war is more related to infec- 
tious disease management, dermatological manage- 
ment, psychiatric management and wound manage- 
ment than to decompression sickness, oxygen convul- 
sion, or the minor neurosis of a still maturing aviator. 
Management of contagion, the skin, the psyche, and 
wounds is central to effective, comprehensive opera- 
tional medicine. This should be reflected in operational 
medicine training programs. 

We propose three possible tracks for a physician de- 
siring a career in operational medicine: 

• Preventive medicine/occupational medicine track. 

• Internal medicine/family practice track. 

• Surgery/ surgical subspecialty track. 
In each training program the proposed G-l year is the 
traditional basic medical, basic surgical program. The 
second year should provide exposure to aviation medi- 



Volume 68, January 1977 



erne, submarine medicine, and other operational tech- 
nology, using facilities close to the naval regional 
medical center that provided G-l training. The G-2 year 
should be under the control of the operational medical 
branch, with students assigned to either the depart- 
ment of medicine or department of surgery. The next 
three years of training, depending on the selected 
track, should complete requirements for board eligibil- 
ity in preventive medicine, occupational medicine, in- 
ternal medicine, family practice, or surgery. The sixth 
and seventh year should be a period of operational 
deployment, to be followed by additional postgraduate 
training if desired. The goals of such a training 
program are: 

• Career retention of operationally oriented medical 
officers. 

• Development of physicians trained in the medical 
support of fleet operations. 

• Development of a highly respected cadre of Medical 
Department personnel who function as advisers on fleet 
operational matters. 

We believe that more is at stake than simply the form 
and substance of operational medicine. Our military 
medical establishment is a unique global laboratory for 
studying applied physiology. Used properly, it can pro- 
vide answers of fundamental biological relevance to the 
relief of human misery. It can give our military medi- 
cine profession a position of leadership among the 
world's medical centers. It can clearly, unequivocally 
and eloquently complement the justification for naval 
medicine's continued involvement in postgraduate 
medical education. Further, it can complement the 
justification for naval medicine's continued involve- 
ment in clinical research, and can strengthen the argu- 
ment for truly reciprocal affiliations with local univer- 
sity medical centers. 

Not to seize these opportunities and these challenges 
will surely lead to our assimilation or destruction as an 
organizational entity. Our uniqueness, our single 
rationale is our ability to understand and mold the mili- 
tary environment to ensure the health and welfare of 
our fighting forces. To this end, we offer the following 
conclusions and recommendations: 

• Current training programs and career development 
policies are not adequate to meet all. fleet operational 
needs and to provide satisfying professional careers. 

• Current attitudes separating operational medicine 
from clinical medicine are divisive and counterproduc- 
tive in meeting operational needs and individual career 
objectives. 

• Military applied physiology has rich potential for pro- 
viding a variety of biomedical models applicable to clin- 
ical medicine. 

• Postgraduate development of clinical skills, knowl- 
edge and attitudes is an appropriate alternate back- 
ground for the operationally oriented medical officer of 
the future. 

• Graduate education in applied physical research in 

21 



the fleet operational environments can improve our 
professional image. , , 

• Current approaches to training in aviation, sub- 
marine, and diving medicine should be restructured. 

• Postgraduate training programs should be restudied 
with the intent of including additional clinical training 
and alternatives in internal medicine, family practice, 
and general surgery. 

• The Bureau of Medicine and Surgery should be re- 
organized to eliminate the hiatus between operational 
and clinical medicine. 

Continuing Medical Education: 
An Expanding Requirement 

CDR B.G. McAlary, MC, USN 

Medical Corps Programs, Naval Health Sciences 

Education and Training Command 

Let's start with a definition. The Association of 
American Medical Colleges, whose task force in 
continuing medical education has recently reported out, 
says that continuing medical education is "all activities 
that result in the maintenance and/or enhancement ot 
the physician's professional knowledge, attitudes and 
skills " Practically speaking, this means that continu- 
ing medical education begins when graduate medical 
education programs end, and that it continues through- 
out our professional lives. This definition, obviously 
broad, deliberately excludes learning that takes place 
during any formal graduate medical education pro- 

gr Why do we have continuing medical education? 
Well, 1 think it's fairly obvious that it exists to improve 
the quality of medical care provided by the health care 
team. Furthermore, continuing medical education is 
part of the movement toward increasing accountability 
in medicine. Beyond these sweeping generalizations, 
however, there exists a morass of unanswered ques- 
tions which justify our seeking your guidance. 

Currently under review at the Bureau of Medicine 
and Surgery is BUMED Instruction 4651.1A-the 
Bureau's attempt to create an equitable funding policy 
for continuing medical education. The purpose in 
issuing this instruction is to identify continuing medical 
education as a need unto itself, and to isolate it from the 
more general categories of short courses, conferences, 
and so forth. , . 

The instruction also has secondary aims; to identity 
the Naval Health Sciences Education and Training 
Command (HSETC) as the "financial parent' ' of people 
assigned to non-BUMED-command activities; and to 
assign to commanding officers of regional medical 
centers primary responsibility for the ongoing educa- 
tion of Medical Department personnel within their 
regions. 



22 



Other reasons for issuing the instruction are to 
eliminate inconsistencies among our five corps by 
establishing guidelines for screening training requests, 
and to make the best use of our resources. For example, 
transcontinental travel and attendance at meetings 
unrelated to present duties is clearly discouraged in 
this instruction. , 

These policies have already been adopted by tne 
corps program directors at HSETC. When HSETC 
approves a request, an entry is made in the individual s 
training record, which is permanently available for re- 
view However, presently continuing medical education 
programs funded by regional medical centers are not 
forwarded for entry into any centralized training 

Let's divert our attention from the Navy and look at 
what the civilian community is facing, since their situa- 
tion is not dissimilar to ours. They are acutely aware 
that a variety of factors are at play. For example, there 
is nonspecific pressure from consumer groups, such as 
groups involved in pre-paid health maintenance 
organizations. There are several state and national 
political influences. As just one example, proof of con- 
tinuing medical education is required for relicensure in 
several states. Also, certain members of Congress are 
continually advocating the reexamination and federal 
licensure of all physicians and would link this require- 
ment to documented continuing medical education. 
Furthermore, many PSRO (Professional Standards 
Review Organization) groups are leaning toward target- 
oriented continuing medical education to compensate 
for what they feel are deficiencies. 

There is the obvious twofold impact of the malprac- 
tice crisis: one result is that continuing medical educa- 
tion is now required by several state malpractice laws; 
another is that malpractice suits may make some physi- 
cians aware of their own need for continuing education. 
Another fact that underlines the concept we are dis- 
cussing is the growth of biomedical knowledge. It is 
impossible for any physician to stay current in his or her 
field without devoting specific time for continuing 
medical education. 

Last but not least among the civilian pressures are 
voluntary and involuntary sources of guidance. An 
example of voluntary guidance is the AMA physician 
recognition award program. On the involuntary side, 12 
state medical societies and six medical specialty socie- 
ties require proof of continuing medical education, even 
for membership. The Joint Commission on Accredita- 
tion of Hospitals also clearly exerts its influence in this 
area We may be assured that the developing role of the 
liaison committee for continuing education, together 
with pending legislation, will further underscore the 
relevance of continuing medical education for the Navy 
community. , 

There remains a host of internal problems which 
compound the wide variation in personal motivation 
necessary for any voluntary continuing medical educa- 

U.S. Navy Medicine 



tion program to succeed. These problems include: 

• Poor understanding throughout the medical com- 
munity of exactly why continuing medical education is 
needed. 

• Episodic and often misdirected means for meeting 
the need for continuing medical education. 

• Little coordination among several interested groups, 
all trying independently to accomplish their goals. 

• Lack of effective audit of the usefulness of any spe- 
cific continuing medical education effort. 

• Limited availability of continuing medical education 
to certain subpopulations of the health care team. 

• Limited research to solve these problems. 

• Few incentives for pursuing continuing medical 
education. Often there is a rather vague coercion which 
can breed more resentment than cooperation. 

To determine where we are headed, we must answer 
a number of questions: Are there any unique Navy 
needs that cannot realistically be met by periodic par- 
ticipation in general medical training as it is presently 
being designed? Should we wait for present or future 
pressures to crystallize, or should we develop our own 
interim requirement and systems? If federal licensure 
occurs, should military physicians be included? Should 
we adopt a mandatory requirement for our own com- 
munities? If so, should we link this requirement to 
credentialing or promotion? 

If we establish those requirements, should the Navy 
or the individual assume the cost? Should separate 
funding be established throughout the Navy? And 
should those funds, as well as recordkeeping responsi- 
bilities be centralized? Or do we maintain the present 
duality between the regional medical centers and 
HSETC? Should an audit system be developed? Should 
it differ among the various subspecialty groups? Should 
we develop a network of continuing medical education 
programs within each region as an integrated compo- 
nent of the regionalization concept? 

These are just samples of the questions that need to 
be addressed if we are to fulfill our management obliga- 
tions of planning and preparedness. 




CAPT H.O. DeFries {MCI questions SAC 8 panel members 

Volume 68, January 1977 



PANEL DISCUSSION 

RADM J.W. Cox, MC, USN 

RADM R. Laning, MC, USN 

RADM E.J. Rupnik, MC, USN 

CAPT J.S. Cassells, MC, USN (moderator) 

CAPT J.J. Quinn, MC, USN 

CAPT R.E. Strange, MC, USN 

CDR B.G. McAlary, MC, USN 

Q. Regarding continuing education: Just exactly what kind of 
continuing education guidelines are we now using at the 
Naval Health Sciences Education and Training Command 
(HSETC) pending the new instruction? What are the con- 
tinuing medical education resources like for this current 
fiscal year? 

CDR McAlary: First of all, total resources for fiscal year 
1977 have not been determined. I do not know at this point 
what funds will be available under the broad category of con- 
tinuing education, but I have every reason to believe that it 
will be less than we want. 

Our present funding guidelines are designed to give fewer 
resources to more people. Each of you will be getting replies 
from HSETC that will reflect these guidelines. In between the 
politely worded no's will be remarks such as, "Don't plan to 
go from one coast to another: we can no longer afford that 
kind of travel." 

We must also keep the cost per person well below $500, if 
possible. If we can do that, we can probably provide resources 
for all of our operational medicine community. Interestingly 
enough, those people seek resources with less enthusiasm 
than do people at BUMED-commanded activities. I think this 
is largely a fault of the system: the operational medicine com- 
munity perhaps doesn't realize that these resources exist; or 
they have been so discouraged in the past when seeking re- 
sources, that they think it's useless to ask. 

Q. How will limitations on PCS (permanent change of station) 
funding impact on the policy of a year in operational medi- 
cine following graduate training year one? 
CAPT Cassells: This problem came up after our original 
decision. There is an impact here that must be evaluated very 
carefully. 

The initial problem— and I think the lesser problem— will 
be to get the students out to the field in the first place. But if 
these constraints persist and we can't adjust the projected 
rotation dates (PRDs), we may have trouble putting our in- 
terns into operational assignments. Their PRDs now are one 
year, so they could continue without creating a problem for 
the computer system at the Bureau of Naval Personnel. 
That's what I'm concerned about. 

Q. CAPT Quinn, where does operational medicine fit in the 
Occupational Health Service? How might it affect our pre- 
ventive medicine programs if people who are trained to 
work in an industrial setting are required to serve one year 
in operational medicine? 
CAPT Quinn: Well, one of our problems is that we don't 
have enough occupational medical officers who are trained 
operationally. They don't bounce back into clinical medicine, 
and we don't have the interplay between, say, internal medi- 
cine and occupational medicine or preventive medicine that 
we would like to have. 



23 



The kind of program we would probably want would involve 
putting students through a basic medical year program, 
through a master of public health degree, whether it be pre- 
ventive medicine or occupational medicine, and then assign- 
ing them dual duties in a Navy shipyard. 

Q. CAPT Quinn, would you comment on the idea some 
people have that operational medicine is not stimulating 
medical practice? I've heard the complaint that there isn't 
a real contingency need, and also that people don 't like 
operational medicine because it means spending a lot of 
time away from home. Wouldn't it be better to have a 
broader-base physician population to draw upon, and 
have our specialists partially trained in operational medi- 
cine so that they could share the load? And wouldn't it 
enhance the esprit de corps of the Navy Medical Corps by 
bringing us into one family instead of two separate 
groups: operational and clinical? 

CAPT Quinn: This is what we are trying to do. By giving 
our operational medicine people a broad base— in internal 
medicine or family practice or surgery, for example— we 
would enable them to alternate between clinical medicine and 
operational medicine. Right now when you get into opera- 
tional medicine you tend to be stuck there unless you have the 
credentials to get back into the clinical medical specialties. 
Once some of our people get into operational medicine, they 
stay there— and I think that's to the detriment of all of us. 

There are many clinicians who don't like to go to sea, and 
there are many clinicians who don't like operational medicine. 
But I think from now on everybody is going to have to like 
operational medicine. 

Q. Are you talking about only a small group of individuals? 

Or about half the Medical Corps participating? 

CAPT Quinn: I don't think you would ever get half the 
Corps to participate. As Bob Strange pointed out, we need 
50% of our people in primary care, and of that 50% I would 
suspect that 15% or 20% would probably be in operational 
medicine. But I'm just guessing at those figures. 

You will never get an ideal situation. I think you'll always 
have to have a small group of people who enjoy the biomedi- 
cal aspects of operational medicine and who enjoy going to 
sea. But you have to give them an opportunity to come back 
into the clinical field. Because right now the people in clinical 
medicine often don't understand the operational side, and 
sometimes vice versa. But I don't think you could ever make 
everybody go to sea. 

Q, What is the general opinion of the Navy physician among 
the line? Do line commanding officers still want ' 'my 
doctor, " or are they accepting new programs of health 
care delivery? 

CAPT Strange: The answer to that is yes in some ways, 
and no in others. What they would like us to be and what we 
are frequently differ. The line, beyond a shadow of a doubt, 
still wants their own physicians; they still want a ship's 
medical officer. 

But I think we can get modern medicine in the Navy 
accepted by all. I'm fairly optimistic that eventually we will be 
able to change these concepts. I also think, however, that 
people who are primarily interested in machinery and events 
will maintain certain attitudes about physicians that we will 
have to adapt to. It has to be a 50-50 proposition. 

RADM Rnpnlk: There are line officers of the World War II 

24 



vintage who tend to be the "my doctor" types. But I think 
that in the past few years, since we introduced the pool con- 
cept, we have convinced the younger line officer that he 
doesn't have to have his own medical officer. Unfortunately, 
the younger line officer is not in a position of authority to turn 
this whole thing around. 

But eventually it will be turned around, so that the line will 
not think of us as "their" medical officers but will rely on the 
medical centers to provide care they need when they deploy. 
Right now there are still those who will have it no other way: 
they want the operational billets filled with their own doctors. 

RADM Laning: You're absolutely right. But there's 
another thing: as a line officer progresses in his career he 
develops an attitude of command. So the young line officer 
who today may be sympathetic with our problem, in the 
future — as he develops a command attitude himself — may 
change and become the traditional line officer. 

RADM Rnpnlk: That may be true. But there's also a 
chance that if a young line officer is not accustomed to having 
his doctor aboard the ship, he is not going to expect us to 
provide medical officers to his own younger line officers when 
he gets into command. 

Q. If our graduate training programs are reduced, do you 
think we would also modify our health care delivery sys- 
tem? Would we reduce our patient population? Or would 
we be asked to do more with less? 
RADM Rupnik: Well, I don't know how accurate my pre- 
dictions are but as 1 look into the future I see a smaller Navy 
Medical Department. And I am talking about all corps. I say 
that because it appears our total military population is on the 
decline. Now obviously if our total military population builds 
up again, we will have a larger Medical Department. The 
results of all the studies that I've seen convince me that we 
are viewed as a commodity that is too expensive. The studies 
suggest that the Navy can only afford the number of physi- 
cians needed to respond to a contingency. And to the extent 
that number of physicians can take care of other patient cate- 
gories when we aren't fighting a war, then that's how many 
patients we'll have. 

A tremendous number of assumptions are made when you 
get into contingency planning. And the decisions depend on 
what the assumptions are in the first place. 

So as I see it, there has got to be a smaller Medical Depart- 
ment with heavier reliance on other health care systems out- 
side the military. The only other solution would be to have 
Congress change the law to give us enough resources to take 
care of the beneficiary categories that we expect will come to 
our door. We don't have that right now. Not with a $10 million 
cut in FY76, and a $3 million cut in the transitional quarter. 

Q. CAPT Strange, as I recall you showed that a sizable 
percent of our hospital-based physicians is serving the 
fleet through the fleet medical pool. Is the problem that 
this information is still not favorably received by the 
senior line officers who are not out with the fleet them- 
selves and who do not see our hospitals as providing fleet 
support? 
CAPT Strange: Yes. We take it on the chin all the time, 
because our regional medical centers really are furnishing 
support. The problem is that the line officers see only how 
many operational billets are filled. We attempt to get our 
point of view across — to show that hospital-based physicians 
support the fleet, too. 

U.S. Navy Medicine 




I I 



\ It 



SAC 8 panel: (left to right) CDR McAlary, CAPT Quinn, CAPT Strange, RADM Rupnik, RADM Cox 



The greatest danger to the pool, frankly, is the computer 
readout and the way it distorts the amount of support we are 
providing. We try to educate the line, but it's partly a control 
issue and partly the product of the age of computers. 

The control issue can't be forgotten. I think that, even if 
there were a medical officer on every ship and in every 
Marine billet, if the billets did not belong to the line com- 
mander he would be dissatisfied because he feels he has to 
have control of his resources. 

So we keep pushing the pool concept, "FAC" (functional 
area coding) coding the billets, and try to get the point of view 
across that the regional medical centers are supporting the 
line. 

RADM Rupnik: We fought this battle about a year ago when 
VADM Watkins took over as Chief of Naval Personnel and 
wanted all operational billets fdled by the end of the year. It 
became apparent that the real problem was a computer 
foul-up, that the fleet was getting the medical care that it 
needed. 

As Bob pointed out, they want to be able to say "That 
doctor is my doctor. He belongs to me. That billet is filled." 
The only way I know of to do that is through FAC coding. This 
is a technique to identify an individual assigned to an opera- 
tional billet but who, under certain factored conditions, would 
work in another area. In other words, we could have Marine 
billets 100% filled, but say 60% would be FAC coded billets, 
so those physicians could be assigned to various regional 
medical centers or other facilities when not needed by the 
Marines. But they would be "controlled" by the commanding 
officer of the unit to which they were assigned. Whenever 
their unit was deployed or had a training exercise, they would 
go out with that unit. The physician "belongs" to the unit, 
but under all other circumstances he would usually work in a 
regional medical center. 

We should have all the billets in the Marine Corps filled by 
the end of this year. The one big hitch is who is going to pay 
the TAD (temporary additional duty) costs when you transfer 
a man from one unit to another. That has not been resolved. 

There recently was a Naval Audit Service study done at 
Port Hueneme in which they suggest the same technique for 
the fleet billets. We are in complete agreement. We think that 
fleet billets ought to be filled the same way. They ought to be 
"FAC'coded billets. Bob Strange's chart showed hospital 
billets 112% filled. If those 12% were actually assigned 
aboard a ship, our chart would not show 112%. It would show 
hospital billets 100% and fleet billets 100%, and the fleet 
wouldn't have a basis for their argument that their billets are 
not being filled. 

CAPT Strange: Whether we like it or not, we are heading 
for the point where hospitals will be staffed by many medical 

Volume 68, January 1977 



officers assigned to the regional medical center on an ADDU 
basis, and whose primary duty is with the fleet. That's what is 
coming, and it's probably the best way to solve the problem. 
It's either that or very few medical officers for your depart- 
ments. 

RADM Rupnik: Right now, under the pool concept, you are 
given a three- month assignment aboard ship and then you are 
brought back and then another physician takes your place and 
is out for three months. This might increase to six months, 
and might be extended for a month before the deployment 
and two weeks after the deployment. So we are talking about 
some deployments being seven months. If you tack a month 
and a half onto that, we are talking about a nine- month de- 
ployment. If you or the members of your staff were given the 
choice between that kind of deployment and a full deployment 
at sea, would it make much of a difference to you? 

Participant: I know of no ship that's deployed for eight 
months. The ship is going to be back in port during that 
period of time. 

RADM Rupnik: No, I know of some ships that are out 
seven months, and what we are talking about is tacking a 
month and a half onto that, so you are away from your region- 
al medical center for 8*/i months. 

I believe that the medical officer who would object to a 
year's assignment to a ship would have the same objections if 
he were assigned to that ship for %Vi months. Do you agree' 
Participant: It depends on the billet. It becomes discrimi- 
natory because the only people who are going to be eligible 
for this program are those who have multiple billets in the 
hospital. You are not going to send your gastroenterologist 
out for eight months or a year if he is occupying the only billet 
at the hospital for gastroenterology. You'll send the general 
internist or the general surgeon. And therefore the program 
becomes discriminatory. 

RADM Rupnik: It is discriminatory, I agree, and when we 
talk about having 50% of our Medical Corps in primary health 
care specialties, I think it would be those general physicians 
who would be called on most frequently to serve with the 
fleet. The superspecialists probably would not be called, if we 
don't have enough of them. Obviously, if you only had one 
neurosurgeon you wouldn't send him out. 

Participant: We have 1.1 million outpatients a year in our 
medical center. I'm not going to give the line control of my 
physicians if they just come in at the last minute and pull the 
physicians out when we have scheduled appointments for 
them. We couldn't take care of our patients. That would put 
us at a terrible disadvantage. 

RADM Rupnik: The commanding officer of the ship or the 
unit would not have absolute control. He would have control 
only under certain factored conditions. And as I understand 

25 



it, there would have to be a clear understanding among the 
Bureau of Medicine and Surgery, the Bureau of Naval Person- 
nel, and the Marine Corps before we went into this. Those 
factored conditions would have to be clearly identified. 

In other words, if the sriip was going out on a deployment, 
you would be notified at least six months ahead of time. And 
if you had, say, 20 of your doctors going on similar deploy- 
ments and your staff was going to be severely reduced, you 
would have time to tell the community that your hospital 
would have to reduce its workload in some areas. It would be 
a very complicated way of doing things, but that's the way it 
would have to operate. 

Similarly, if the Marines were going out on a training exer- 
cise, they would have to give you enough advance notice so 
you could compensate for the loss of physicians and corpsmen 
at your facility. 

One way that we would try to decrease the impact on any 
one facility would be to spread the "FAC" coded billets 
throughout the U.S. So if one unit went out, let's say from 
Camp Lejeune, you wouldn't wipe out the hospital at Camp 
Lejeune. You might take a few billets from all around the 
country. That's expensive, but it might be an answer. 

Q. I think the American public is starting to recognize the 
role of the allied medical personnel— the nonphysician— 
in direct, primary care. So it seems to me we could try to 
educate our line commanders to the fact that nonphyst- 
cians can fill some of these requirements. I am talking 
about the supertrained technicians, whether you call them 
physician 's assistants or better-trained independent duty 
corpsmen. They are supported by modem technology— 
teletransmission and videotransmission capability— and 
by better methods of patient evacuation. There are plenty 
of so-called medical officer billets that don 't have to have 
medical officers in them. Do you agree? 
RADM Rupnik: You are absolutely right, but our problem 
is that we'do not identify line controlled billets. Line con- 
trolled billets are identified by our line bosses. We advise our 
line bosses as to whether they need a billet or not, but in the 
final analysis they decide whether they want a physician in 
that billet or whether they want a physician's assistant or an 
independent duty corpsman. I agree that there are many, 
many instances where physicians are not necessary, where a 
physician substitute or a physician's assistant can be used. 

Of course, we are currently utilizing physician's assistants 
and independent duty corpsmen. If you compare what we are 
doing now with what is done during times of war, you'll see 
that we are using many, many more physician substitutes 
aboard our smaller vessels than we do during wartime. 

The final answer is to get more people, and as I told you in 
the beginning, we are not getting larger numbers of people 
unless Congress changes the law. 

Q. The physicians who are deploying now are expecting a 
three-month rotation. When do you expect a change in the 
program? 

RADM Laning: Momentarily. It is being decided right 
now. Incidentally, you must realize these long deployments 
are mainly in the Pacific fleet, not the Atlantic fleet. 

Q. RADM Rupnik, are these shortened deployments going to 
be affected by the increasing number of women coming 
aboard under the scholarship program? 
RADM Rupnik: Sure. The more women we have, the fewer 



men we have— and so these fewer men are going to have to be 
deployed more often. 

Q. How can we get women physicians aboard combat ves- 
sels? 
RADM Rupnik: We can't. That's a rule under the law that 
we have to adhere to. There is no way that we can get around 
that. 

Q. Those of us in the field can only guess at what the mood in 
Washington is, but we have a feeling that the prevailing 
mood now is toward the line getting whatever they want. 
Are we doing anything to ensure that the line is aware of 
our problems in the delivery of health care? 
RADM Rupnik: You may be assured that every flag officer 
in this room has talked at length to his line counterpart and 
explained the realities of the present situation. There comes a 
time, however, when your employer says, "You will do such- 
and-such" and you have two choices: either you do it, or you 

quit. 

Participant; I find that many of our line colleagues are in- 
fluenced by the criticism they hear in our regional medical 
centers about the medical care provided to the fleet. In the 
past you had to have two years in operational medicine before 
you were even considered for a residency. But then everybody 
said it was a terrible waste of time, and we should let people 
get on with their specialty education. So for a while we elimi- 
nated the requirement for operational experience. Now we 
are going back to that, but we've got to be sure that people 
know that these primary care physicians are providing excel- 
lent medicine. Our academic people must support that con- 
cept when talking to the line, instead of saying, "Oh, look at 
all the mistakes the ship's doctor or the guys out in the field 
made" or "Boy, if they had come in to us, we would have 
treated them differently." We are undermining ourselves. 

RADM Rupnik: Well, I would like to think that doesn't 
happen very often in our health care facilities. I don't think 
that's the reason for the changes. The changes have occurred 
in response to periods of austerity. The bottom line in every- 
thing we are saying today is money. We are vying with 
weapons systems that are very expensive. Our line counter- 
parts can't get enough money to build the weapons systems 
they think they need to carry out their mission, and they want 
us to take our share of the cut. 

In the budget process, we go through what is called the 
"increment-decrement process." If we want something new, 
if we want something in addition to what we have now, we've 
got to identify something of equal value that we can give up. 
Or if they take a decrement on the line side, we take a share of 
that decrement on the Medical Department side. Even so, the 
line is looking for another way of obtaining health care ser- 
vices that would be less expensive than it is today. 

If I were a line officer looking ahead five or ten years and I 
thought some other agency would take over health care in the 
U.S., I might be thinking like the line is thinking. I'd think, 
"Turn the dependent care over to somebody else. Let's just 
take care of the active-duty people." If you look at their side 
of it, they are not being illogical. It is costing them. 

But we are looking at it from our side. We have an out- 
standing health care delivery system, and we would hate to 
see its quality diminished. But again, you get down to dollars. 
How much money is the Navy or the Congress willing to give 
us to support the total beneficiary categories that they are ac- 
countable for by law? 

U.S. Navy Medicine 



Motes & Announcements 



DENTAL CONTINUING EDUCATION 
COURSES SET FOR MARCH 

These dental continuing education courses will be 
offered in March 1977; 

National Naval Dental Center, Bethesda, Md. 

Complete dentures 14-18 Mar 1977 

Occlusion 28-30 Mar 1977 

Eleventh Naval District, San Diego, Calif. 

Oral surgery 7-11 Mar 1977 

Preventive dentistry 28-30 Mar 1977 

U.S. Army Institute of Dental Research, Walter Reed 
Army Medical Center, Washington, D.C. 

Periodontics 740 Mar 1977 

Requests for courses administered by the Comman- 
dant, Eleventh Naval District, should be submitted to: 
Commandant, Eleventh Naval District (Code 37), San 
Diego, Calif. Applications for other dental continuing 
education courses should be submitted to: Command- 
ing Officer, Naval Health Sciences Education and 
Training Command (Code 5), National Naval Medical 
Center, Bethesda, Md. 20014. Applications should 
arrive six weeks before the course begins. 

CONTINUING EDUCATION FOR NAVY NURSES 

The Naval Health Sciences Education and Training 
Command will sponsor the following continuing educa- 
tion courses for Navy nurses: 

Hypertension: A Symposium for Nurses (30 credit hours) 
9-13 May 1977 NRMC Oakland, Calif. 

Covers nursing management of the hypertensive patient: 
treatment, risk factors, morbidity, mortality and etiology. 
Open to nurses whose primary interest is medical nursing. 

Innovations in Ambulatory Health Care (30 credit hours) 
28 Feb-4 Mar 1977 NARMC Pensacola, Ha 
21-25 Mar 1977 NRMC San Diego, Calif. 

Emphasizes latest concepts in outpatient medical care. De- 
signed for nurses working with ambulatory patients. 

Current Aspects of Maternal-Child Health (30 credit hours) 
24-28 Jan 1977 NRMC Long Beach, Calif. 

18-22 April 1977 NRMC Jacksonville, Fla. 

A seminar for obstetric and pediatric nurses, focusing on 
nursing management of maternal and infant care in inpatient 
and ambulatory settings. Practical aspects of hospital care, 
equipment and therapy, and the changing role of the obstetric 
and pediatric practitioner will be considered. 

Volume 68, January 1977 



Approximately 40 participants will be accepted for 
each course. The courses are open to Nurse Corps offi- 
cers not currently assigned to an overseas billet; 
however, nurses assigned to Argentia, Newfoundland; 
Bermuda; Guantanamo Bay, Cuba; Keflavik, Iceland; 
and Roosevelt Roads, Puerto Rico, who have served at 
least six months on active duty may apply. The courses 
are also open to Nurse Corps officers of the inactive 
Reserve on a space-available basis. 

A list of accommodations will be forwarded to officers 
accepted for the courses. A limited number of spaces 
may be available in the bachelor officer quarters (BOQ) 
of the host regional medical center; reservations may 
be made by writing to the BOQ officer. 

Nurse Corps officers wishing to attend these courses 
should apply to the Naval Health Sciences Education 
and Training Command (Code 7), National Naval Medi- 
cal Center, Bethesda, Md., 20014, following proce- 
dures set forth in the BUMED Instruction 1520.8 series. 
Applications should be submitted several weeks before 
a course begins. 



LEARNING DISABILITY CLINIC OPENS 

A clinic for treating children with learning dis- 
abilities has opened in the Optometry Service of 
Naval Regional Medical Center, Corpus Christt, 
Tex. Children are referred to the clinic by their 
school or by a medical center pediatrician. After 
clinic staff members determine that the child is 
physically healthy, they administer a battery of 
tests to ascertain whether the child's visual de- 
velopment and performance, refractive status, 
ocular health or psycholinguistic ability plays any 
part in his learning disability. Parents receive re- 
ports describing their child's visual strengths and 
weaknesses, and suggesting a treatment plan. 



Pediatric optometrist examines patient in new clinic 




Reserves 



Project Readiness 77 



In 1973 and 1974, the Naval Re- 
serve was restructured along func- 
tional lines according to the recom- 
mendations of the Reserve Analyti- 
cal Study Project (RASP). In its final 
form, implemented under the au- 
thority of OPNAV Note 5400 of 
various dates in 1973 and 1974, the 
Selected Reserve was divided into 
ten major mission platforms and 24 
subprograms of the Eleventh Pro- 
gram, Special and General Support. 
Although much turbulence accom- 
panied this major reorganization, 
valuable lessons have been learned. 
With respect to the Medical Pro- 
gram, at least, a balanced force 
representing all health corps has 
been developed, and a cordial, co- 
operative working relationship has 
grown between active medical com- 
mands and the Reserve community. 

The fundamental unit of the 
Medical Program was the naval 
regional medical center reinforce- 
ment unit. These units contained 
billets for 950 officers and 1,877 en- 
listed and had as their mission the 
replacement of active personnel 
deployed from regional medical 
activities in support of the Fleet 
Marine Force upon mobilization. 
These were relatively low priority 
units in the context of the entire 
Reserve force, but they were well 
received on the active side and they 
did represent a new kind of training 
opportunity for all personnel, par- 
ticularly hospital corpsmen, some 
nurses, and others who were not 
currently actively engaged in the 
health care field. Unit manning, 
initially slow to develop, has now 
risen to more than 67% for officers, 
and about 79% for enlisted; now 
drilling in the Medical Program are 
308 Medical Corps officers, 50 
Dental Corps officers, 120 Medical 
Service Corps officers, 163 Nurse 
Corps officers, and some 1,490 
enlisted personnel. In addition to 



the foregoing naval regional medi- 
cal center units, there were estab- 
lished eight preventive medicine 
units (which were of higher priority 
and had a mission in support of the 
fleets and the Fourth Marine Divi- 
sion) and 40 naval regional dental 
centers. 

Among the several objectives of 
the Chief of Naval Operations when 
he assumed that office was Objec- 
tive 4.2: to determine the size and 
structure of the Naval Reserve. 
OP-605E was tasked with this re- 
sponsibility. To validate the Se- 
lected Reserve requirements gath- 
ered from the total personnel re- 
quirement for full mobilization, 
OP-605E examined the Mobilization 
Manpower Allocation Resources 
Plan (M-MARP) of all major man- 
power claimants, and developed a 
notional figure of 101,600 for the 
Selected Reserve. The documents 
were delivered to each major man- 
power claimant, alone with the 



guidelines for submission. Each 
claimant was then asked to note his 
own mobilization requirements from 
mobilization until mobilization, plus 
three months. The guidelines were 
stringent and, for the most part, 
carefully followed. For a billet in the 
M-MARP to qualify as a billet in the 
Selected Reserve, it must be time- 
sensitive, that is, it must be filled in 
the first three months of mobiliza- 
tion. The assignment must require 
training, and the training must be of 
a type that the Navy can provide in 
the normal course of reserve drills 
and active duty for training. Finally 
— and this was most important for 
the Medical Program— the billet 
must support combat operations 
and must not simply augment the 
shore establishment. 

In light of the last requirement, 
the naval regional medical center 
unit mission and mobilization as- 
signment could not meet OP-605E 
criteria for Selected Reserve. 
Another program in the OPNAV 
Note 5400 series that contained 
large numbers of Medical Depart- 
ment personnel was Program 9, the 
Marine Corps Forces Program. In 
the Restructured Reserve, Program 
9 was the naval support to the 





CNO 






1 








BUMED - 36 
OP-09RH 




(OP-Q9R) 
CHIEF OF NAVAL RESERVE | 










1 



READINESS 
COMMANDER 



NAVAL RESERVE 
CHAIN OF COMMAND 



MCPO OF 
COMMAND 



JUDGE 
ADVOCATE 



ADMINISTRATION 



X 



CHIEF OF STAFF 



TRAINING AND 

PROGRAM 
MANAGEMENT 



LOGISTICS/ 
BUDGETING 



MANPOWER 



MEDICAL 

LT (MSC) 

HMCS 



VARIOUS 
PROGRAM 
OFFICERS 



This abbreviated diagram dc-e-'S not sho 
functions of the Readiness Command. 



MARINE 
CORPS 



MOBILIZATION 



'CATEGORY A - Shaded rsaarve blllotW 



This organization chart shows how Medical Reservists fit Into the new structure 
of the Naval Reserve. 

U.S. Navy Medicine 



Fourth Marine Amphibious Force, a 
large nationwide Reserve organiza- 
tion under the claimancy of the 
Commandant of the Marine Corps 
and directed by an active- duty Com- 
manding General and his staff at 
Camp Pendleton, Calif. The sub- 
mission to OP-605E by the Com- 
mandant included, in addition to the 
support for the Fourth Marine Divi- 
sion, other substantial require- 
ments for the First, Second and 
Third Marine Amphibious Forces 
which are active organizations at 
Camp Pendleton, Camp Lejeune, 
and Okinawa. 

Submissions from other claimants 
showed a general decline in num- 
bers of Medical Department per- 
sonnel. The Chief of the Bureau of 
Medicine and Surgery submitted 
Selected Reserve billet require- 
ments representing the eight pre- 
ventive medicine units, 20 surgical 
and surgical support teams, four 
surgical platoon cadres and a neuro- 
surgical augment, and two small 
advanced-base hospitals. The war- 
fare sponsor for the new LHA-1 
class of amphibious ships submitted 
billets sufficient to man the sepa- 
rate hospital capability designed 
into these ships, of which one, USS 
Tarawa, is in commission. In the 
final accounting, substantial billet 
losses are recorded in all health 
corps officer communities, with a 
slight increase in total requirements 
for hospital corpsmen. Table I 
shows current and projected billet 
strength in all programs and all 
health corps communities except 
dental, along with the numbers of 
personnel presently in a drill pay 
status. 

Other major changes accompany 
the realignment of the Selected Re- 
serve. Whereas RASP designed a 
program along functional lines and 
specifically identified a program 
sponsor for every function and 
every drilling reservist, OP-605E 
has created a model that integrates 
structure, function, and ultimate 
mobilization responsibility. In con- 
sonance with the policies of the 
Surgeon General, medically man- 
aged programs of the Selected Re- 



TABLE I. Medical Reserve Billets 
and Bodies 





Medical 






Medical 
Corps 


Service 
Corps 


Nurse 
Corps 


Hospital 
Corps 


Current billets: 








Marines 148 
Medical 488 
Other 283 


9 

224 

21 




220 

40 


1344 
2037 
1307 


Total 919 


254 


260 


4688 


Projected billets (Project Readiness '77 1 


Marines 381 
Medical 107 
Other 171 


67 
66 
48 


56 
91 
13 


3449 
646 
709 


Total 659 


181 


160 


4804 



serve will now, and for the foresee- 
able future, stress operational med- 
ical support. It follows, then, that 
training programs and objectives 
will be tailored to the several mis- 
sions now identified for the Medical 
Reserve, maintaining the emphasis 
on professional matters that has 
proved so successful in the naval 
regional medical center units of the 
past. 

On 1 Oct 1976, all responsibilities 
of the district commandants for 
reserve affairs were transferred to 

TABLE II. Naval Reserve 
Readiness Commands 



Naval Reserve Readiness Command, 

Region One, Newport, R.I. 
Naval Reserve Readiness Command, 

Region Two, Scotia, N,Y, 
Naval Reserve Readiness Command, 

Region Four, Philadelphia, Pa. 
Naval Reserve Readiness Command, 

Region Five, Ravenna, Ohio 
Naval Reserve Readiness Command, 

Region Six, Washington, D.C. 
Naval Reserve Readiness Command, 

Region Seven, Charleston, S.C. 
Naval Reserve Readiness Command, 

Region Eight, Jacksonville, Fla. 
Naval Reserve Readiness Command, 

Region Nine, Millington, Tenn. 
Naval Reserve Readiness Command, 

Region Ten, New Orleans, La. 
Naval Reserve Readiness Command, 

Region Eleven, Dallas, Tex. 
Naval Reserve Readiness Command, 

Region Thirteen, Great Lakes, III. 
Naval Reserve Readiness Command, 

Region Sixteen, Minneapolis, Minn, 
Naval Reserve Readiness Command, 

Region Eighteen, Olathe, Kans. 
Naval Reserve Readiness Command, 

Region Nineteen, San Diego, Calif. 
Naval Reserve Readiness Command, 

Region Twenty, San Francisco, Calif. 
Naval Reserve Readiness Command, 

Region Twenty-two, Seattle, Wash. 



16 Readiness Commands (RED- 
COMs) (Table II), and the personnel 
from the six Reserve Supplements 
were transferred from the staffs of 
the district commandants to the 
staffs of the readiness commanders. 
Accompanying this modification in 
the chain of command, the Marine 
Corps Forces Program, soon to be 
the largest single resource area for 
Medical Department personnel, will 
pass under the administrative con- 
trol of the REDCOM. The interface 
between drillers of the Naval Re- 
serve and the Inspector Instructor 
and the Commandant of the Marine 
Corps will be handled by a Selected 
Reserve Marine officer, a billet for 
whom has been established on the 
REDCOM staff. Medical Programs 
will continue to be managed by an 
active-duty Medical Service Corps 
officer on each of five leading RED- 
COM staffs at Philadelphia, 
Charleston, Great Lakes, New Orle- 
ans, and San Diego. At each of the 
other REDCOMs a senior hospital 
corpsman will be assigned. On the 
inactive side, a Selected Reserve 
billet for an 0-5 or an 0-6 in 
Category A in designator 2105 or 
2305 has been established on the 
Readiness Command staff. Admin- 
istration of the Medical Program in 
the field is thus considerably de- 
centralized and the chain of com- 
mand is modified. Not all the 16 
REDCOMs are fully operational at 
this time. Those indicated above as 
leading Readiness Commands are 
continuing to perform the major 
responsibilities of the Reserve Sup- 
plements which they have replaced. 
Manning of the other REDCOMs is 
expected to reach 80% to 90% by 
mid-1977. 

The foregoing is the genera) 
shape of the medically managed 
programs of the Selected Reserve 
for Fiscal 1977. These billets are 
solid and defensible, if not flame- 
proof. It is a firm base on which to 
expand the reserve force over the 
next two years, as the second itera- 
tion of the Medical Contingency 
Study comes to be reflected in 
specific mobilization billets. — 
BUMED Code 36. 



Volume 68, January 1977 



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